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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202848
Report Date: 06/03/2022
Date Signed: 06/03/2022 11:16:08 AM

Document Has Been Signed on 06/03/2022 11:16 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:JADENS ARF LLCFACILITY NUMBER:
435202848
ADMINISTRATOR:PEREZ, JOCELYNFACILITY TYPE:
735
ADDRESS:5914 TANDERA AVENUETELEPHONE:
(650) 278-1110
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
06/03/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jocelyn PerezTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) David Marrufo and Licensing Program Manager Sarah Yip conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Jocelyn Perez.

Administrator Cristobal reports that there are currently 1 COVID-19 positive residents and 0 COVID-19 positive staff.

During today's tele-visit, the following recommendations were made to the facility:

1. Wash and store cloths after use
2. Put sign on bathroom for COVID residents stating it is for COVID residents only
3. Keep COVID bathroom closed
4. Wash COVID resident's clothes last and use highest water temperature possible
5. Put a liner on the hamper used for COVID resident's laundry

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with with Administrator Perez. A copy of the report will be sent to her for it be signed and returned to CCL.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2022
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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