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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202766
Report Date: 05/12/2022
Date Signed: 05/13/2022 09:34:11 AM

Document Has Been Signed on 05/13/2022 09:34 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:VILLA GLEN HOME ONEFACILITY NUMBER:
435202766
ADMINISTRATOR:TEODORO,ELVIE B.&DR.RIVERAFACILITY TYPE:
735
ADDRESS:1727 CURTNER AVE.TELEPHONE:
(408) 393-8075
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 6DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Peter CortesTIME COMPLETED:
05:00 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 Peter Cores Lead 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 covered trash containers. Hand Washing sign posted and the kitchen. LPA observed supply of Personal Protective Equipment (PPE). COVID 19 signs posted included Symptoms of COVID 19, Cough Etiquette, COVID 19 Self Monitor, Are You Feeling Ill, How Can I Protect Myself from COVID 19, and Cleaning For COVID 19.

LPA reviewed the facility policies and procedures to include screening, visitation, masking, isolation and disinfecting,

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

LPA reviewed report with Peter Cortes Lead Caregiver 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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