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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202779
Report Date: 12/06/2021
Date Signed: 12/06/2021 03:46:55 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2021 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20210322110613
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:
12/06/2021
UNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Jocelyn RealTIME COMPLETED:
12:39 PM
ALLEGATION(S):
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Facility is not maintained in a sanitary condition.
INVESTIGATION FINDINGS:
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THIS IS AN AMENDED LIC9099 DUE TO NEW INVESTIGATIVE FINDING..
On 03/30/2021 and 04/30/2021 LPA interviewed ADM and toured the facility with ADM. LPA observed the facility followed the COVID protocol. No left over foods or dirty dishes were observed in kitchen sink. No left over food or dirty dishes were observed in dining area. Kitchen and dinning area were observed in sanitary condition. LPA observed the common area, restrooms and bedrooms were in sanity condition. On 04/30/2021, LPA interviewed 5 residents, all the residents were satisfied with the facility living environment. All the residents like the facility staff. The facility has routines of house keeping every day. The facility staff clean and sanitize living room, kitchen, and dining area in the morning every day. The facility staff clean resident bedrooms, beddings, and restrooms every day; clean and sanitize all rails, doorknobs, chairs and tables every day; and mop the floors every day. The facility staff do the laundry every day. The facility staff clean the front yard and back yard every day. Every day after dinner, the facility staff clean and sanitize the common area and mop the common area floor. ADM stated the facility disinfects the high touch area often.

Continued, see LIC 9099-C, pages 2 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20210322110613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/06/2021
NARRATIVE
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The department has investigated the above allegations. Based on the investigation, observations, records reviewed, and interviews conducted, the Department found that the
above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. This report was provided to ADM for signature. 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: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2