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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294128
Report Date: 01/24/2023
Date Signed: 01/24/2023 04:41:26 PM

Document Has Been Signed on 01/24/2023 04:41 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:CLARK'S VILLAFACILITY NUMBER:
435294128
ADMINISTRATOR:CLARK, DINA D.FACILITY TYPE:
740
ADDRESS:947 HOWARD AVE.TELEPHONE:
(408) 310-2647
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 5DATE:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Dina ClarkTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Licensee, Dina Clark.

During visit, LPA toured the facility to include the living room, dining room, kitchen, resident rooms, bathrooms, backyard, and garage. Facility's temperature maintained at 73 degrees Fahrenheit. LPA observed the facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. The facility has a cooler filled with emergency supplies located in the garage. Staff present are fingerprint cleared and associated to the facility.

Facility has a designated entry point for symptom screening, temperature check, and sign in for all visitors. Face mask required sign posted at the entry. Hand sanitizer, face masks, and gloves made available at the entry. Bathroom supplied with hand washing sign, paper supplies, and hygiene products. Facility staff clean and disinfect multiple times daily and as needed. LPA observed facility's Personal Protective Equipment (PPE) supplies. Facility staff were provided training on infection control and the Licensee plans to renew their annual training, ASAP. LPA reviewed the facility's policies and procedures to visitation, testing for COVID-19, and isolation. The following posters observed to include but not limited to social distancing and cough etiquette.

LPA observed the sliding door in the master bedroom to be blocked by a resident's night-stand and the exterior to be blocked by a medium sized table. Licensee immediately moved both items that were blocking the exit area. See LIC9102 for additional information.

The following documents were requested by Monday 1/30/2023: LIC610D and LIC500.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with License, Dina Clark and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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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