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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202883
Report Date: 11/01/2022
Date Signed: 11/01/2022 02:49:56 PM


Document Has Been Signed on 11/01/2022 02:49 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MINA'S ELDERLY CAREHOME 2FACILITY NUMBER:
435202883
ADMINISTRATOR:ABBASVAND, MINAFACILITY TYPE:
740
ADDRESS:15095 GARDEN HILL DRIVETELEPHONE:
(408) 348-8361
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY:6CENSUS: 0DATE:
11/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Mina AbbasvandTIME COMPLETED:
02:46 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced pre-licensing inspection today. LPA met with Administrator (ADM) Mina Abbasvand. At 01:34am, LPA toured the facility inside and out. A screening station was observed by the entry door for anyone coming into the facility. The facility is equipped with connected smoke detectors. The smoke detector located in the living room by the entry was tested and observed to be working. A carbon monoxide detector located in bedroom #1 was tested and observed working. A fire extinguisher was observed in the kitchen. The kitchen, dining and living room were furnished and observed to be in good repair.

Resident bedrooms were observed to be furnished and in good repair, with clean linens and adequate lighting. Facility temperature observed to be maintained at 68* F Bathrooms were observed to be clean. The water temperature was measured in bathroom #1 and #2 at approximately 85* F. Cabinet with non-perishable food supply and locked cleaning supplies were observed in the kitchen. Sharps observed to have designated and locked drawer. Centrally stored medication cabinet with lock was observed in the kitchen. Facility emergency lightning observed throughout the facility. 30+ days supply of PPE observed in outdoor storage unit. A complete first aid kit was inspected. The backyard was inspected. All outdoor and indoor passageways were observed clear and free of obstruction. No bodies of water observed.

Component III orientation was waived for this facility due to ADM’s experience. The physical plant is approved pending the adjustment of facility water temperature to within acceptable levels and the completion of Centralized Application Bureau (CAB) review of the facility application. Exit interview conducted with and copy of report provided to Mina Abbasvand.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
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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