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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294192
Report Date: 07/21/2022
Date Signed: 07/21/2022 02:23:35 PM


Document Has Been Signed on 07/21/2022 02:23 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: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:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Serapia BeltranTIME COMPLETED:
01:58 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 07/21/2022 at 01:11pm. LPA encountered administrator Serapia Beltran (Admin) outside the front door. Admin was leaving the facility to meet with a family, and gave caregiver Floro Taon (CG) permission to conduct the inspection on her behalf.

LPA toured the facility, including front hallway, kitchen, living room, all bedrooms, all bathrooms, dining room, back yard and laundry room. Upon entrance to facility, LPA was screened for symptoms and temperature was taken. All staff observed to be wearing masks. Admin confirmed that all staff and all but one residents have been vaccinated.

Facility noted to have a 30 day supply of masks, N95s gloves, face shields, and gowns. No prohibited items noted in resident rooms. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to have been inspected in June of 2022. All cleaning supplies and chemicals noted to be in locked cabinets and closets.

Smoke/carbon monoxide detectors were tested and observed to be operational. Hand washing signs were observed in the facility bathrooms. Water temperature observed to be 115.3 *F in facility bathroom. Facility temperature observed to be 71*F. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. This report was reviewed with facility caregiver Floro Taon, and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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