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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294175
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:14:22 PM


Document Has Been Signed on 04/08/2022 04:14 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MONROE RESIDENTIAL CARE HOMEFACILITY NUMBER:
435294175
ADMINISTRATOR:ROJAS JR, VICENTE P.FACILITY TYPE:
740
ADDRESS:673 N. MONROE STREETTELEPHONE:
(408) 243-1135
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:6CENSUS: 3DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rojas VicenteTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the annual 1-year required inspection focusing on infection control. LPA met with Administrator Vicente Rojas.

During visit, LPA toured the facility inside and outside to include the living room, kitchen, resident rooms, bathrooms, hallway, and backyard. All fire exit routes were free and clear of obstruction. All residents observed to be non-ambulatory.

Facility observed to have a designated entry point for COVID-19 symptoms screening. Bathrooms observed to be supplied with hygiene products, paper supplies, and hand washing signs. Hand sanitizer available. Facility cleans and disinfect daily and as needed. LPA observed supply of Personal Protective Equipment (PPE). Trash can with lid located in every resident rooms. All staff are fully vaccinated and boosted. All staff observed to be wearing a mask. N95 fit testing was provided by the Assistant Administrator who is a Registered Nurse. The following posters were observed to include: symptoms of COVID, cover your cough, visitation policy. LPA reviewed facility's policies and procedures to isolation and infection control training.

LPA informed Administrator to submit Infection Control Plan to CCLD by 06/30/2022 and review PIN 22-13-ASC. The following documents were obtained to include Administrator Certificate, Facility Sketch, and LIC610.

No citations were issued per the California Code of Regulations, Title 22.

This report was reviewed with Vicente Rojas and a copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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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