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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202857
Report Date: 02/10/2022
Date Signed: 02/10/2022 04:21:54 PM

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:DJ'S CAREHOMEFACILITY NUMBER:
435202857
ADMINISTRATOR:REAL, JOCELYNFACILITY TYPE:
740
ADDRESS:4318 KINGSPARK DRIVETELEPHONE:
(408) 464-2245
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 6DATE:
02/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Jocelyn RealTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Steve Chang conducted a pre licensing inspection visit, and met with administrator (ADM) Jocelyn Real. Upon arrival, staff Basilic Rowan (S1) took LPA body temperature and checked LPA into the guest book. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. COVID posters were observed at the main entrance and in facility. 3 staff and 6 residents were observed in facility.

LPA toured the facility inside out with ADM. LPA inspected living room, kitchen, dinning area, laundry room and garage. Medication closet, knives closet, and cleaning product closet were observed locked. There are 3 shared resident rooms at first floor for residents, and 2 restrooms for residents at first floor. There are 2 staff live-in rooms, 1 office room, one storage room, and 1 restroom at the second floor in facility. Beds in shared bedrooms were observed 6 feet apart. Trash cans were observed with covers. ADM stated facility will put washing hands signs by the sinks. Paper towels were observed with holders. ADM stated facility will remove the cloth towel in kitchen. Room temperature was observed at 70 degree F, and hot water temperature was observed at 110 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 11/23/2021. LPA inspected the backyard, there was no obstruction to block the walkway. ADM stated all staff are fully vaccinated and done with booster shots. Component III orientation was conducted with ADM.

No deficiency or issue noted during inspection. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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