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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202760
Report Date: 05/12/2022
Date Signed: 05/13/2022 09:29:41 AM

Document Has Been Signed on 05/13/2022 09:29 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
CCLD Regional Office,
, CA
FACILITY NAME:NORTH STAR RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202760
ADMINISTRATOR:LIRA, ARLENE MARY AGONOYFACILITY TYPE:
735
ADDRESS:1617 ADRIAN WAYTELEPHONE:
(408) 258-8618
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: 5DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Arlene Lira and Lina AgonoyTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Arlene Lira Administrator and Lina Agonoy Caregiver.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Medications, sharp objects, toxins, cleaning supplies are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Hand sanitizer available to visitors and residents. Bathrooms observed to be supplied with hygiene products and foot operated trash containers. Hand Washing signs posted in the bathrooms and in the kitchen near the sinks. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included Visitation Policy, Stop- Screeing Required Before Entering, COVID 19 Symptoms, Stop Are You Feeling Sick, How Can I Protect Myself from COVID 19, Cough Etiquette and Social Distancing.

LPA reviewed the facility policies and procedures to include screening, Infection Control Preventionist certification, visitation, testing, masking, isolation and disinfecting,

No citations were issued per the California Code of Regulations Title 22.

LPA reviewed report with Arlene Lira Administrator and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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