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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202823
Report Date: 03/15/2022
Date Signed: 03/15/2022 04:37:53 PM

Document Has Been Signed on 03/15/2022 04:37 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:APOLLO ADULT DAY PROGRAMFACILITY NUMBER:
435202823
ADMINISTRATOR:LAUREL, PATRICK M.FACILITY TYPE:
775
ADDRESS:888 CAPITOL AVETELEPHONE:
(408) 439-2636
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 150CENSUS: 123DATE:
03/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Patrick LaurelTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Steve Chang, and Licensing Program Manager (LPM) Romeo Manzano, and Program Clinical Consultant (PCC) MiraBelle Villamin conducted Technical Assistant - PCC through tele-inspection (Zoom), and met with Administrator (ADM) Patrick Laurel.

The purpose of this TA 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. The facility has two screening stations including hand sanitizer, thermometer, glove, questionnaires, and a visitor log book at the screening stations.

The facility common areas were inspected such as the kitchen, dinning area, bathrooms, classrooms, conference rooms, and hallways were observed. Some trash cans were observed without covers, ADM stated the facility will replace the trash cans with covers in 3 days. There were no paper towels near the sinks, ADM stated the facility will fix this issue in 1 day. ADM stated the facility will put more washing hands posters and COVID posters in facility. PPE supplies were observed sufficient.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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: APOLLO ADULT DAY PROGRAM
FACILITY NUMBER: 435202823
VISIT DATE: 03/15/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to frequently wipe and disinfect high touch areas.
2. Facility to have trash cans with foot pedal cover.
3. Facility to conduct staff training at least monthly or frequently such as donning and doffing PPE and COVID -19 updates.
4. N95 Seal check reference:
https://www.cdc.gov/niosh/docs/2018-130/pdfs/2018-130.pdf
https://www.youtube.com/watch?v=oU4stQgCtV8
5. Facility to review PINs (Providers’ Information Notification) through CCLD website: www.ccld.ca.gov.
6. Facility to reference https://youtu.be/H4jQUBAlBrI - donning PPE.
7. facility to reference https://youtu.be/PQxOc13DxvQ - doffing PPE.
8. facility to reference https://youtu.be/KmyxsnuREGs - How does viruses spread from surfaces to people.
9. facility to reference https://youtu.be/pIAH2l9Eg6g - How does viruses make you sick.
10. Facility to reference https://youtu.be/TCa7Gg1NUD4 - Why does contact time matter for disinfection.

No deficiencies cited during today's Tele Visit. Exit interview conducted with ADM.
A copy of this report emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC809 (FAS) - (06/04)
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