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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294128
Report Date: 01/22/2025
Date Signed: 01/22/2025 04:01:27 PM

Document Has Been Signed on 01/22/2025 04:01 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/
DIRECTOR:
CLARK, DINA D.FACILITY TYPE:
740
ADDRESS:947 HOWARD AVE.TELEPHONE:
(408) 310-2647
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Dina ClarkTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to conduct the facility's annual required 1 year inspection. LPA met with Administrator, Dina Clark.

During visit, LPA toured the facility with staff to include the dining room, living room, kitchen, garage, resident bedrooms, bathrooms, and backyard. All fire exit routes were free and clear of obstruction. All staff are fingerprint cleared and associated to the facility.

The facility's temperature was maintained at 72 degrees Fahrenheit. Resident bedrooms observed with beds, linens, night stands, dressers, and adequate lighting. Bathrooms observed with hygiene products and paper supplies. Hot water temperature maintained at 109 degrees Fahrenheit. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 26 degrees Fahrenheit. Freezer temperature maintained at below 0 degrees Fahrenheit. Sharp objects observed locked. Chemicals and disinfectants observed locked in the garage. Fire extinguisher last services on 10/07/2024. Carbon monoxide detector observed present and operable.

LPA reviewed 3 resident files. 3 out of 3 files contained an admission agreement, medical assessment, TB result, personal rights, consent forms, and appraisal/needs and services plan. LPA advised ADM to ensure the safeguard of personal property and valuables form are filled out, even if resident and/or their authorized representative declines to safeguard any items. ADM stated understanding. LPA reviewed centrally stored medications and centrally stored medication records to be maintained.
See LIC809-C.
Sarah YipTELEPHONE: (408) 324-2131
Christine DoloresTELEPHONE: (408) 334-8552
DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 VILLA
FACILITY NUMBER: 435294128
VISIT DATE: 01/22/2025
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LPA reviewed 3 staff files. 3 out of 3 staff are fingerprint cleared and associated to the facility. 3 out of 3 staff files contained a health screening, TB result, and training records. Staff are provided training to include emergency preparedness, dementia/Alzheimer's, medications, oxygen use, postural support. and hospice services.

Facility has an infection control plan. LPA observed PPE supplies located in the garage. Facility has an emergency disaster plan. Emergency drills are being completed quarterly, with the last drill completed in 01/03/2025. Facility has an emergency bin located in the garage. LPA observed a supply of flashlights and batteries.

ADM mailed requested documents to update the facility's file to the Department on 01/17/2025.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Dina Clark and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
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