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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294192
Report Date: 07/11/2024
Date Signed: 07/11/2024 04:21:40 PM


Document Has Been Signed on 07/11/2024 04:21 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:QUINTON SMART, GLADYSFACILITY TYPE:
740
ADDRESS:1545 SHAW DRIVETELEPHONE:
(408) 960-8847
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 5DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Lead Staff, Floro TaonTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Lead Staff, Floro Taon and stated the purpose of today's visit. LPA Rai observed 2 staff and 4 residents at the facility. During the visit, 1 residents was out of the facility. At this time, there is 1 resident on Hospice services and facility has a Hospice waiver for 4 residents.
During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 1 storage shed in the backyard which was not used as habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.
LPA Rai observed 2 staff rooms that were not labeled in the facility sketch on file with the Department. LPA Rai spoke with Administrator (ADM) Gladys Smart who stated she will follow up with Licensee to provide LPA Rai an updated fire clearance and facility sketch. LPA Rai observed an updated facilty sketch in the family room with the staff rooms labeled on the sketch.
LPA Rai toured 4 Out of 4 resident bedrooms, which had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 118.2 degrees F - 118.4 degrees F. The water temperature in the kitchen sink was 118.4 degrees F. Fire extinguisher was observed and inspected on 6/17/2024. Facility smoke detectors and carbon monoxide detectors are in working condition.

LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai reviewed resident medications and central stored medication records.

No deficiencies were cited per California Code of Regulations, Title 22. Technical Assistance was provided. This report was reviewed with Lead Staff, Floro Taon and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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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