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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202754
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:59:29 PM

Document Has Been Signed on 09/15/2022 04:59 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PRIMAVERA GARDENSFACILITY NUMBER:
435202754
ADMINISTRATOR:MICHAEL ELSOUSOUFACILITY TYPE:
740
ADDRESS:16095 CHURCH STREETTELEPHONE:
(408) 778-5683
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 20CENSUS: 16DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:TIME COMPLETED:
05:05 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 and met with Lead Supervisor, Lisa Lanford.

During visit, LPA toured the facility to include the living room, dining room, resident rooms, bathrooms, and exterior. Toxins and sharp objects observed secured. All staff observed to be wearing a face mask.

Facility has a designated entry point for symptom screening and temperature check for all visitors and staff. LPA advised to include the full list of symptoms for the visitor symptom screening log. Hand sanitizer made available at entry. Bathrooms supplied with hygiene products, paper supplies, and hand washing signs. LPA observed the facility's Personal Protective Equipment (PPE) supplies. LPA advised to obtain a 30 day supply of PPE. Staff have been provided training on infection control. Staff clean and disinfect multiple times daily and as needed. The facility has procedures to isolation, testing, and visitation. Staff have not been provided N95 fit-testing.

The following posters observed to include feeling ill, special visitors, social distancing, cough etiquette, and cleaning for COVID.

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

This report was reviewed with Lisa Lanford and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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