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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294192
Report Date: 07/21/2021
Date Signed: 07/21/2021 03:16:05 PM

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:A HOME AT SHAWFACILITY NUMBER:
435294192
ADMINISTRATOR:BELTRAN, SERAPIA D.FACILITY TYPE:
740
ADDRESS:1545 SHAW DRIVETELEPHONE:
(408) 960-8847
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 5DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gladys SmartTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Karen Taku conducted an unannounced annual (Infectious Control) Inspection today. LPA met with Administrator (ADM) Gladys Smart.

At 10:10am, LPA entered the facility through the designated entry point and was screened by staff. All staff were observed wearing face coverings. At 10:25am, LPA was accompanied by the ADM during a tour of the facility, inside and out. LPA observed hand sanitizer readily available in all resident bedrooms. All three restrooms were observed with hand washing posters, liquid soap, paper towels, and a touchless trash can. COVID-19 prevention posters were observed in the main dining/living room area. LPA observed an adequate supply of PPE readily available to staff. Backyard/patio area observed in good repair.

Per Administrator, routine symptom screening is conducted twice a day. The facility is currently accepting visitors inside and in the backyard patio area of the facility. All visitors are required to wear mask when visiting inside the facility.



LPA obtained copies of the following documents during visit:
1. LIC 500- Personnel Summary
2. LIC 308- Designation of Administrative Responsibility
3. LIC 610- Emergency Disaster Plan
4. Current Administrator's Certificate

The facility is adhering to the COVID-19 Mitigation Plan approved on 3/18/21.



No deficiencies were cited. Exit interview conducted with the ADM and a copy of this report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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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