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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202824
Report Date: 11/30/2022
Date Signed: 11/30/2022 10:59:16 AM

Document Has Been Signed on 11/30/2022 10:59 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
CENTRAL COAST CR/RES, 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:
(669) 284-8920
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: 0DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jeffrey Hayes and Marissa NguyenTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the annual inspection focusing on infection control. LPA met with Administrator (ADM), Jeffrey Hayes and Marissa Nguyen.

During visit, LPA toured the facility to include the living rooms, resident rooms, bathroom, kitchen, and backyard. No residents observed on-site. ADM states the residents are attending day program.

Facility has a designated entry point for symptom screening, temperature check, and sign in for all visitors. Facility has a required mask sign posted at the front door. Hand sanitizer, face masks and gloves made available at entry. Bathroom supplied with hand washing sign, hygiene products, paper supplies, and trash bin with lid. LPA observed facility's Personal Protective Equipment (PPE) supplies. LPA recommended ADM to clean and disinfect the facility at least three times a day, and as often as needed. Staff are N95 fit-tested. LPA reviewed the facility's procedures with ADM to include visitation, isolation, screening for signs / symptoms of COVID-19, and testing for COVID-19.

The following posters observed to include but not limited to required mask, social distancing, hand hygiene, symptoms of COVID, droplet precaution, special visitors, and donning and doffing PPE.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Administrator, Jeffrey Hayes and Marissa Nguyen and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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