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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202867
Report Date: 05/20/2022
Date Signed: 05/20/2022 04:52:39 PM

Document Has Been Signed on 05/20/2022 04:52 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:WARNER HOME #2FACILITY NUMBER:
435202867
ADMINISTRATOR:GALLEON, ARMANDFACILITY TYPE:
735
ADDRESS:3068 FLORENCE AVE.TELEPHONE:
(831) 917-2870
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 0DATE:
05/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Pam SloanTIME COMPLETED:
11:59 AM
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Licensing Program Analyst (LPA) Steve Chang conducted a pre licensing inspection visit. LPA waited outside of the facility for 25 minutes to wait for Licensee Pam Sloan (LNS) to come. LPA met with Licensee (LNS) Pam Sloan and administrator (ADM) Armand Galleon. Upon arrival, LNS took LPA body temperature and checked LPA into the guest book. No COVID poster were observed at the main entrance and in facility. LNS stated the facility will put the COVID posters on within 3 days. No Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. COVID posters were observed at the main entrance and in facility. LNS stated the facility will setup the screening station within 3 days.

LPA toured the facility inside out with LNS. LPA inspected living room, family room, kitchen, dinning area, and laundry room. Medication closet, knives closet, and cleaning product closet were not observed locked. LNS stated the facility will install lockers for Medication closet, knives closet, and cleaning product closet within 3 days.

There are 3 shared resident rooms at first floor for residents, and 2 restrooms for residents at first floor. There is 1 staff live-in rooms at the second floor in facility. Some trash cans were observed without covers. LNS stated the facility will change all the trash cans with covers. Paper towels were observed with holders. Room temperature was observed at 70 degree F, and hot water temperature was observed at 110 degree F. No resident was observed in facility.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. LNS tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 03/19/2022. LPA inspected the backyard, there was no obstruction to block the walkway. LNS and ADM are fully vaccinated and done with booster shots. Component III orientation was conducted with LNS and ADM.

Exit interview was conducted with LNS and ADM. This report was provided for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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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