435202789-3-8-2021-26-AS-JROA-BYWLVB-20210308080513

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202789
Report Date: 03/05/2021
Date Signed: 03/08/2021 08:05:45 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:	DELIA'S RESIDENTIAL COMMUNITY 3		FACILITY NUMBER:	435202789
ADMINISTRATOR:	DOMINGO, DINA		FACILITY TYPE:	740
ADDRESS:	175 BLAKE AVE		TELEPHONE:	(408) 799-6239
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	6	CENSUS: 2	DATE:	03/05/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Dina Domingo		TIME COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Joanne Roadilla conducted a pre-licensing tele-inspection visit today via Zoom. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. The home is currently licensed as Andrea's Elderly Care Facility #4 facility #435202482, with 2 residents in care. The pre-licensing is for a change of ownership. LPA met with Administrator (ADM) Dina Domingo. At around 3:20pm, LPA toured the facility virtually with ADM. LPA observed COVID-19 related posters at the entrance to promote social distancing and infection control. A screening station is located by the back entry door for checking temperature of any visitors, residents or personnel coming in through the facility. There were complaint, ombudsman, and resident's personal rights posters observed in the hallway. The facility is equipped with smoke and carbon monoxide detectors, both were tested and observed working. Fire extinguishers were observed by room #6, by the dining area and the main door and were all last serviced on March 19, 2020. The kitchen, dining and living room were observed in good repair. LPA observed at least a 2-day supply of perishable and 7-day supply of non-perishable foods. Resident bedrooms were observed in good repair, fully furnished, with clean linens and adequate lighting. Bathrooms were observed clean and equipped with grab bars and non-skid mats. At 3:35pm, water temperature in bathroom #1 across the hallway was measured at 113.3 degrees F. Continued on page 809-C.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

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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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: DELIA'S RESIDENTIAL COMMUNITY 3	FACILITY NUMBER: 435202789
	VISIT DATE: 03/05/2021

NARRATIVE

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At around 3:40pm, a complete first aid kit was inspected. Centrally stored medications, cleaning supplies and other toxic substances were observed in locked cabinets. All outdoor and indoor passageways were observed clear and free of obstruction. No bodies of water observed.

Component III orientation was waived for this facility. There were no issues noted during the pre-licensing tele-inspection. The physical plant is approved pending the completion of Centralized Application Bureau (CAB) review of the facility application. Exit interview conducted with and copy of report sent to Dina Domingo to sign and mail back to CCL.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

LIC809 (FAS) - (06/04)

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