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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202857
Report Date: 02/08/2023
Date Signed: 02/13/2023 04:51:49 PM


Document Has Been Signed on 02/13/2023 04:51 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: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:
02/08/2023
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jocelyn RealTIME COMPLETED:
09:50 PM
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Licensing Program Analysts (LPAs) Steve Chang, Simi Rai, Manuel Monter, and Licensing Program Manager (LPM) Romeo Manzano conducted Technical Assistant (TA) through tele-inspection (ZOOM) and met with Administrator (ADM) Jocelyn Real.

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, questionnaires, hand sanitizer, face masks, thermometer. Living room, dinning room, kitchen, 2 restrooms, laundry room, 3 resident shared rooms were observed in the facility.

Trash cans with covers were observed in restrooms. One trash can in laundry room and one trash can at backyard were observed without covers. ADM stated the facility will replace the trash cans with covers within 3 days. 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. PPE supplies were observed sufficient.

ADM stated the facility separates the laundry load for each resident, did the negative case laundry first and uses high temperature for the laundry. The facility already submitted the Infection Control. Plan to CCL office.

Based on today's inspection, the facility is being recommended the following:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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: DJ'S CAREHOME
FACILITY NUMBER: 435202857
VISIT DATE: 02/08/2023
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1. Facility to replace the trash cans in laundry and at the backyard with trash cans with cover.

2. Facility to have the cabinet and lock for the detergent in the laundry room.

3. Facility to have PPE station at outside of each isolation room instead of at the entrance of the hall way.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC809 (FAS) - (06/04)
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