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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294192
Report Date: 09/02/2021
Date Signed: 09/02/2021 04:14:22 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:
09/02/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Pia Beltran and Gladys SmartTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted a Technical Assistance (TA) tele-visit today via Teams Meeting with Program Clinical Consultant (PCC) Nurse Helen Shi, RN and Licensing Program Manager (LPM) Jackie Jin. The purpose of the visit was to provide guidelines for Infection Prevention and Control. Present during the tele-visit were licensee Pia Beltran, administrator (ADM) Gladys Smart and staff Floro Taon (S1).

The facility was toured virtually, and the following areas were inspected: central entry, living room, dining room, kitchen, bathrooms, and residents' bedrooms. Based on facility tour and interview with ADM and S1, the following recommendations were provided today:

1. Keep thermometer by the screening station.
2. Keep the isolation rooms closed.
3. Covered trash bin for PPE disposal should not be inside the bathroom. The donning station should be separate from the doffing station.
4. Keep supplies for disinfecting near the isolation rooms.
5. Load laundry separately between clients and disinfect the area after each load.

No deficiencies issued per Title 22 of the California Code of Regulations. LPA reviewed report with, and a copy provided to Gladys Smart for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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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