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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202793
Report Date: 11/04/2021
Date Signed: 11/05/2021 07:58:44 AM

Document Has Been Signed on 11/05/2021 07:58 AM - 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:KOEN ARFFACILITY NUMBER:
435202793
ADMINISTRATOR:KOEN, DEREKFACILITY TYPE:
735
ADDRESS:1620 RAVENS PLACE WAYTELEPHONE:
(646) 423-7601
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
11/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Catherine KoenTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Steve Nguyen conducted an unannounced Annual Required 1 Year Infection Control site visit and met with Catherine Koen Administrator.

LPA toured the facility inside and out to include but not limited to: kitchen, dining room, living room, bedrooms, bathrooms and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in a locked medication room. Toxins, cleaning supplies, knives and sharp objects are secured. Interior temperature 71 degrees Fahrenheit.

In the kitchen LPA observed a minimum of 3 day perishable food supply and 7 day non perishable food supply.

Facility observed to have designated entry point for universal symptom screening. All restrooms observed to be supplied with hygiene products. Hand washing signs were posted in bathrooms. Hand sanitizer available to residents. Facility observed to have adequate supply of Personal Protective Equipment (PPE). Staff observed wearing masks.

LPA reviewed the facility policies and procedures to include screening, isolation, disinfecting, staffing, training, supplies, PPE usage and social distancing.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Catherine Koen Administrator and a copy provided,
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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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