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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202727
Report Date: 08/19/2022
Date Signed: 08/19/2022 11:57:25 AM

Document Has Been Signed on 08/19/2022 11:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:TRANQUILITY HOMEFACILITY NUMBER:
435202727
ADMINISTRATOR:FEATHERSTON, REBECCAFACILITY TYPE:
737
ADDRESS:17343 SERENE DRIVETELEPHONE:
(831) 818-7981
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 4CENSUS: 0DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rebecca Featherston-LopezTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection to focus on infection control. LPA let with Program Administrator, Rebecca Featherston-Lopez.

During visit, no clients observed in the facility and were stated to be on an outing.

LPA toured the facility to include the office, dining room, living room, kitchen, bedrooms, bathrooms, and garage. LPA observed the central entry point to include a poster of the visitor guidelines. Staff conducted a temperature check at entry and verbally asked for symptoms of COVID-19. Staff screen for symptoms of COVID prior to starting their shift using a QR code. Hand sanitizer available. Bathrooms supplies with hygiene products, paper supplies, and hand washing sign. Staff clean and disinfect multiple times daily and as needed. LPA observed facility's Personal Protective Equipment (PPE) supplies. Clients are being monitored for symptoms multiple times daily and frequently, if needed. Staff are N95 fit-tested. LPA reviewed facility's procedures to training, isolation, visitation, and testing requirements.

LPA observed the facility's food storage located in one of the bedrooms to contain non-perishables foods and toxic substances in one area. LPA advised to separate the non-perishables foods and toxic substances.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Administrator, Rebecca Featherston-Lopez and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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