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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202826
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:39:38 PM

Document Has Been Signed on 02/03/2023 02:39 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:LOUPE ADULT RESIDENTIAL FACILITY INC.FACILITY NUMBER:
435202826
ADMINISTRATOR:VALENZUELA, JALANOFACILITY TYPE:
735
ADDRESS:1257 LOUPE AVENUETELEPHONE:
(408) 620-1254
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 4CENSUS: 4DATE:
02/03/2023
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:JALANO VALENZUELATIME COMPLETED:
01:55 PM
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Licensing Program Analysts (LPAs) Steve Chang, Simi Rai, Manuel Monter, and Licensing Program Manager (LPM) Jackie Jin conducted Technical Assistant (TA) through tele-inspection (ZOOM) and met with Administrator (ADM) JALANO VALENZUELA.

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. A screening station was observed at main entrance including screening visitor log book, hand sanitizer, face masks, thermometer. Living room, family room, dinning room, kitchen, 2 restrooms, laundry room, 4 resident single rooms and 2 staff live-in rooms were observed in the facility.

Trash cans with covers were observed in restrooms. Posters of washing hand for 20 seconds were observed by the sinks in restrooms and kitchen. Soap liquid were observed by the sink in kitchen and restrooms. Paper towels were observed with holders. Cloth towel was observed in kitchen. PPE supplies were observed sufficient.

ADM stated the facility separates the laundry load for each resident and uses high temperature for the laundry.

Based on today's inspection, the facility is being recommended the following:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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: LOUPE ADULT RESIDENTIAL FACILITY INC.
FACILITY NUMBER: 435202826
VISIT DATE: 02/03/2023
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1. Facility to update the screening questionnaire to include more COVID symptoms.

2. Facility to update the visitor log book to include more columns for the symptoms.

3. Facility to replace the trash can in the cabinet in kitchen with a trash can with cover.

4. Facility to submit an updated Infection Control Plan.

5. Facility to remove the cloth towel in kitchen.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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