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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202824
Report Date: 10/05/2021
Date Signed: 10/05/2021 04:50:56 PM

Document Has Been Signed on 10/05/2021 04:50 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:LYRIC LODGEFACILITY NUMBER:
435202824
ADMINISTRATOR:HAYES, JEFFREYFACILITY TYPE:
735
ADDRESS:1306 VINCI PARK WAYTELEPHONE:
(702) 510-9690
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: 0DATE:
10/05/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jeffrey HayesTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an announced pre-licensing inspection. LPA met with the Prospective Administrator (PA). Fire clearance granted this facility a capacity of total 6 residents. This facility was a 1 story building. This facility was licensed in another area, planned to move to this location once approved. There was no resident in the current location.

LPA toured the facility inside and outside. At the entrance, there were COVID-19 precaution signs. The facility was well lit and in good repair, LPA did not see any damaged window screens, cracked floor, or broken furniture, etc. The fire place had a glass screen. Facility's living room, dining room, and 3 residents' rooms for 6 residents had functioning light fixtures. Hot water temperature was measured at 116.1 degrees F in the 2 restrooms. Detergents were stored in the locked cabinet in the garage. There was a functioning refrigerator in the kitchen. The centrally stored medication had a lock present, ready for storage. First-aid kit was examined and contained all required components per regulation. LPA tested the carbon monoxide/smoke detectors and alarms, they appeared to be functioning. Fire extinguishers were fully charged, last serviced in 6/8/2021. There was no obstruction in all passageways inside the facility, and there was no obstruction in any of the emergency exits. There was no open body of water outside of the facility. Component III orientation was given to PA.

This application pending the approval of the PA's administrator certificate renewal or hiring a certified administrator. The physical plant is approved pending the completion of Centralized Application Bureau (CAB) review of the facility application.

This report was reviewed with PA. A copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2021
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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