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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294155
Report Date: 07/27/2022
Date Signed: 08/22/2022 11:22:33 AM


Document Has Been Signed on 08/22/2022 11:22 AM - 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:ST. ANNE'S HOME FOR ELDERLYFACILITY NUMBER:
435294155
ADMINISTRATOR:BANAAG M., MANALO MAYLENEFACILITY TYPE:
740
ADDRESS:790 LAKEBIRD DRIVETELEPHONE:
(408) 744-1752
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:6CENSUS: 4DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Melinda Banaag and Maylene ManaloTIME COMPLETED:
11:10 AM
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On 07/27/2022, Licensing Program Analyst (LPA) Mandeep Kaur conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Melinda Banaag and Maylene Manalo, Administrators. Upon entrance of the facility, LPA's temperature was measured.
LPA toured the facility inside and out. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked cabinet in the kitchen.

Facility observed to have designated entry point for COVID 19 symptom screening. Hand sanitizer available to visitors and residents. LPA toured 3 bedrooms and all of the Bathrooms observed to be supplied with hygiene products.

Foot operated trash containers observed in the bathrooms and in the kitchen. LPA observed supply of Personal Protective Equipment (PPE).
The main kitchen was inspected. There was sufficient perishable food for at least 2 days and nonperishable food for at least one week.
All staff members were observed to be wearing masks.
No citations were issued per the California Code of Regulations Title 22.
LPA reviewed report with Melinda Banaag and Maylene Manalo, Administrator and a copy provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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