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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294206
Report Date: 08/25/2021
Date Signed: 08/25/2021 11:04:45 AM

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:KIMBERLY'S ELDER KARE KOTTAGEFACILITY NUMBER:
435294206
ADMINISTRATOR:KENDALL HALLFACILITY TYPE:
740
ADDRESS:2770 MOORPARK AVENUETELEPHONE:
(408) 483-1029
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:6CENSUS: 4DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kendall HallTIME COMPLETED:
11:20 AM
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Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan conducted an unannounced annual required inspection. LPAs met with Kendall Hall, Administrator.

During today's visit LPAs toured the facility inside and outside. LPAs observed a central entry point and screening area for all visitors and staff. Facility has 6 private resident rooms and 3 staff rooms.

Bathrooms have supplies of paper towels and soap available for staff, residents, and visitors. Trash cans were observed covered with lid. LPAs observed the following posters, coughing and sneeze etiquette, social distancing, and hand washing. Facility has a sufficient amount of PPE supplies. Facility disinfect and sanitize high touch surfaces daily and as needed. Facility has a mitigation plan in place to prevent the spread of COVID-19.

RO office will gather additional PPE supplies to make available for pick-up. LPAs will send additional informational links on PPE usage to include donning and doffing PPE and seal check of N95 masks.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Kendall Hall, Administrator. 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: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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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