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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202774
Report Date: 05/20/2022
Date Signed: 05/20/2022 04:53:27 PM

Document Has Been Signed on 05/20/2022 04:53 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:WARNER HOME #1FACILITY NUMBER:
435202774
ADMINISTRATOR:ARMAND GALLEONFACILITY TYPE:
735
ADDRESS:3710 WARNER DRIVETELEPHONE:
(831) 917-2870
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 6DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Pam SloanTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Licensee (LNS) Pam Sloan, and Administrator (ADM) Armand Galleon. Upon arrival, staff Abu Kallon (S1) took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with LNS. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, glove, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towel in kitchen was observed with holder. Three shared resident bedrooms, and laundry room were inspected. One staff live-in room is in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 107 degree F in facility. One residents and 1 staff were observed in facility.

Fire extinguisher was serviced on 10/31/2021. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

LNS stated all the residents and staff are fully vaccinated and done with booster. No citation were noted today. Exit interview was conducted with LNS. This report was provided to LNS for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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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