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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202730
Report Date: 09/28/2022
Date Signed: 09/28/2022 12:57:56 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/28/2022 12:57 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LOVEWAYS CARE HOMEFACILITY NUMBER:
435202730
ADMINISTRATOR:DUMANTAY, MARJORIEFACILITY TYPE:
735
ADDRESS:3601 EMMANUEL CTTELEPHONE:
(408) 818-0134
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Madonna DumantayTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Madonna Dumantay . Upon arrival, HM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with HM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Living room, family room, kitchen, dining room and three restrooms were inspected. Some trash cans were observed without covers. HM stated HM will put all the trash cans with covers in 5 days. Paper towels were observed with holders. Kitchen had the poster of washing hands but did not have the posters of washing hands for 20 seconds. HM stated HM will put the posters of washing hands for 20 seconds in kitchen in 5 days. 3 shared resident bedrooms, 1 staff live-in room and laundry room were observed. Cloth towels were observed in kitchen and restrooms. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 75 degree F, and hot water temperature was at 105 degree F in facility. 2 residents and 3 staff were observed in facility.

Fire extinguisher was serviced on 05/22/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. LPA reviewed the 6 resident file binders. The resident files are up to date.

HM stated all the residents and staff are fully vaccinated and done with booster. HM stated the facility already submitted the Infection Control Plan to CCL Office. No citation were noted today. Exit interview was conducted with HM. A copy of the report was provided to HM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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