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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202829
Report Date: 04/25/2022
Date Signed: 04/25/2022 01:29:51 PM

Document Has Been Signed on 04/25/2022 01:29 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:BETTER LIVING RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202829
ADMINISTRATOR:BASA, SHARONFACILITY TYPE:
735
ADDRESS:7459 PEGASUS CTTELEPHONE:
(408) 224-6224
CITY:SAN JOSESTATE: CAZIP CODE:
95139
CAPACITY: 6CENSUS: 6DATE:
04/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sharon BasaTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a pre-licensing visit and met with Sharon Basa, Administrator and Eleanor Bass, Licensee.

There are currently residents living at the facility. The facility has an approved fire clearance for 6 non-ambulatory.

LPA toured the facility inside and outside to include the living room, kitchen, bathroom, bedrooms, garage, and backyard. Resident bedrooms were equipped with proper furniture and lighting. Bedding and linens are available to the residents and observed clean. Bathrooms are equipped with grab bars, nonskid floors, hygiene supplies, and toiletry. Activities and games are available for residents. Facility is equipped with cups, plates, utensils, and cooking supplies. Hot water temperature was measured at 110 degrees Fahrenheit.

Medications were observed in a locked cabinet. LPA reviewed six centrally stored medication records with residents medications. LPA observed first aid kit with the following supplies: bandages, scissors, tweezers, and thermometer. Sharp objects and cleaning supplies observed locked.

LPA observed two days worth of perishables and seven days worth of nonperishable.

Facility is equipped with smoke detectors, carbon monoxide detectors, and fire extinguisher. Emergency lighting available when needed. Hallway and passageways were observed free of obstruction.

See LIC-809C for additional information.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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: BETTER LIVING RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202829
VISIT DATE: 04/25/2022
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The following posters observed: if you see something say something and resident rights.

LPA reviewed six resident files and four staff files. Facility staff are fingerprint cleared. Resident files all consist of Admission Agreement, Medical Assessment with TB Information, Consent Forms, Care Plans, Safeguard for Personal Properties and Valuables, and Personal Rights. Staff files all consist of Personal Record, Health Screening with TB Information, and Criminal Record Statement.

Component III was conducted with Administrator.

No issues noted during this pre-licensing inspection.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Sharon Basa, Administrator and a copy of this report provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC809 (FAS) - (06/04)
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