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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202779
Report Date: 08/12/2020
Date Signed: 08/12/2020 01:38:30 PM

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:REAL ELDERLY CAREFACILITY NUMBER:
435202779
ADMINISTRATOR:REAL, JOCELYNFACILITY TYPE:
740
ADDRESS:4858 POSTON DRIVETELEPHONE:
(408) 440-2441
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 6DATE:
08/12/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jocelyn RealTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an announced Prelicensing visit over Facetime video conference call and met with Administrator Jocelyn Real. The visit was conducted over Facetime due to the ongoing COVID-19 Shelter-in-place order throughout the county and state.

During visit, LPA was given a tour through the facility kitchen. LPA observed a fire extinguisher with a service tag dated from June 2020. LPA observed a locked cabinet which, when opened, was seen to contain client medications. The refrigerator was stocked full of food and the pantry had canned food as well. Additional food supplies were later observed in the garage refrigerators. Signs were posted in the resident dinning room including Ombudsman complaint hotlines, resident rights, emergency disaster plans, and more. The first aid kit was observed to have bandages, scissors, tweezers, and a manual.

LPA Marrufo observed residents to be watching television in the living room.

LPA Marrufo was given a tour of three out of three resident bedrooms. Each bedroom had two beds, each with bedding, sheets, blankets, and pillows. Each resident room had two dressers and lighting.

LPA observed two out of two resident bathrooms. The bathroom water temperature was 105 F. The bathrooms had locked storage underneath the sinks for cleaning supplies. The bathroom showers had anti-slip mats and shower chairs.

See LIC809-C for more information. Page 1 of 2.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: REAL ELDERLY CARE
FACILITY NUMBER: 435202779
VISIT DATE: 08/12/2020
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LPA Marrufo observed Administrator Jocelyn Real testing the smoke detectors in three out of three resident bedrooms, the hallway bathroom, and the hallway. Each smoke detector functioned properly when tested.

LPA Marrufo was given a tour of the outside area of the facility. LPA Marrufo observed the gates to open without obstruction. LPA Marrufo did not observe any tools or sharp objects in the backyard area. LPA Marrufo was given a tour of two out of two outdoor storage areas and the laundry room.

LPA Marrufo observed four out of four staff records and found them to have criminal records clearances. LPA Marrufo observed six out of six resident records and found them to each have pre-admissions appraisals and signed admissions agreements and physician's reports.

LPA Marrufo reviewed the Component III PowerPoint slides via Zoom with Administrator Jocelyn Real.

Pre-licensing is complete and this facility has no deficiencies.

This report was reviewed with Administrator Jocelyn Real. This report will be sent to Administrator Real to be reviewed, signed, and returned to LPA Marrufo.

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SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2