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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202785
Report Date: 12/28/2021
Date Signed: 12/28/2021 03:57:17 PM

Document Has Been Signed on 12/28/2021 03:57 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,
, CA
FACILITY NAME:AFRA RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202785
ADMINISTRATOR:ARINES, DIOSDADO EMMANUELSFACILITY TYPE:
735
ADDRESS:686 ARDIS AVETELEPHONE:
(408) 247-1101
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 6CENSUS: 0DATE:
12/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Farnoosh EbadatTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Farnoosh Ebadat Licensee. The facility does not have any residents in care at this time.

LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathroom, and exterior. All fire exit routes were free and clear of obstructions.

The facility has a Mitigation Plan for Epidemic Outbreak Specific to COVID 19. LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, supplies, PPE usage, and Fit Testing.

No citations issued per the California Code of Regulations Tittle 22.

LPA reviewed report with Farnoosh Ebadat Licensee and a copy of this report emailed due to technical issues.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
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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