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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202779
Report Date: 01/06/2022
Date Signed: 01/06/2022 02:09:51 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: 5DATE:
01/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jocelyn RealTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Steve Chang, licensing Program Manager (LPM) Romeo Manzano, and Program Clinical Consultant (PCC) Roxane Fangon conducted Technical Assistant - PCC through tele-inspection (Zoom),and met with Administrator (ADM) Jocelyn Real.

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance including screening questionnaire forms, hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station.
Two staff were observed in facility.

The facility common areas were inspected such as the kitchen, living room, family room, dinning area, bathrooms were observed. There are 3 resident shared bedrooms, 1 staff live-in bedroom, and 2 bathrooms in facility. Trash cans with covers, paper towels with holders, and washing hands signs by the sinks were observed. The laundry room was observed and inspected. The resident bedrooms were inspected. The beds in the shared rooms were observed in 6 feet apart.

ADM stated all the residents and staff are fully vaccinated and finished with booster shots.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
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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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: 01/06/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to wipe and disinfect high touch areas more often.

2. Remove the extra chairs in living room, family room, and dining area to keep social
distancing.

3. Separate the laundry loads for positive and negative cases.

4. Use high hot temperature with laundry machine for COVID positive cases.

No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to the facility for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC809 (FAS) - (06/04)
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