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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294105
Report Date: 06/08/2021
Date Signed: 06/08/2021 03:06:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:LEE'S CARE HOMEFACILITY NUMBER:
435294105
ADMINISTRATOR:CORAZON MILLARESFACILITY TYPE:
740
ADDRESS:5225 GALLANT FOX AVE.TELEPHONE:
(408) 841-9508
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:6CENSUS: 6DATE:
06/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Corazon MillaresTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced COVID-19 Infection Control Required 1 Year visit and met with Corazon Millares.

During visit, LPA Marrufo observed 3 out of 3 resident bedrooms, living room area, 1 out of 1 resident bathrooms, hallways, dinning area, and outdoor area. LPA Marrufo observed that staff and residents were wearing face masks and there was hand sanitizer available at the front door. LPA Marrufo observed the facility PPE supply and found it to be adequate.

LPA Marrufo observed that the facility had a visitor screening log that did not include questions with COVID-19 screening questions. LPA Marrufo observed that the resident bathroom did not have a trash can with a foot-operated lid.

Advisory Notes were issued. See LIC9102 for more information.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Administrator Corazon Millares and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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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