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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202779
Report Date: 08/30/2021
Date Signed: 08/31/2021 08:32:06 AM

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:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Jocelyn Real, ADMTIME COMPLETED:
10:39 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Annual Inspection, and met with administrator (ADM) Jocelyn Real. Upon arrival, LPA addressed the purpose of today's visit to ADM. ADM took LPA's body temperature, asked LPA the infection control/prevention questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. LPA observed the COVID-19 posters in the facility. LPA observed 2 staff (S1, S2) and 6 residents (R1 - R6) in the facility. There are 3 resident shared rooms, one staff live-in room, and 2 restrooms in the facility. LPA observed all the trash cans with covers, and all the paper towel with holders. LPA observed the washing hand signs around the sinks. LPA observed all the staff wore face masks, and all the residents were 6 feet apart. LPA observed the beds in the resident shared rooms are 6 feet apart.

LPA checked the food supplies. The food supplies for 2 day perishable foods and 7 day non perishable foods were sufficient. LPA observed medication cabinet was locked. LPA observed the knives were locked. LPA observed detergents were locked. LPA checked the PPE supplies were sufficient.

ADM stated facility only allows two residents sit at the dinning table at one time. ADM stated all the staff and residents are fully vaccinated.

No citation was issued during today's inspection. Exit interview conducted with ADM. This report was provided to ADM to review and to sign. A copy of this report was emailed to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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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