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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202857
Report Date: 02/13/2023
Date Signed: 02/13/2023 04:50:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/13/2023 04:50 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:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jocelyn RealTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with administrator (ADM) Jocelyn Real. Upon arrival, ADM 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. 2 staff and 6 residents were observed in facility.

LPA toured the facility inside and 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 3 staff live-in rooms, 1 office 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. Posters of washing hands for 20 seconds were observed by the sinks in kitchen and restrooms. Paper towels were observed with holders. 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 1/16/2023. LPA inspected the backyard, there was no obstruction to block the walkway. ADM stated all staff are fully vaccinated and done with booster shots.

ADM already submitted the Infection Control. Plan to LPA. No citation 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: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
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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