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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294206
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:34:55 PM


Document Has Been Signed on 08/03/2022 04:34 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: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: 5DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Annabelle EsperanzaTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator, Annabelle Esperanza.

During visit, LPA toured the facility to include the living room, kitchen, dining room, resident rooms, bathrooms, office, and backyard. All fire exit routes are free and clear of obstruction. All staff observed wearing a face covering.

Facility temperature maintained at 72 degrees Fahrenheit. LPA observed 2 days worth of perishables foods and 7 days worth of non-perishable foods.

Facility has a designated central entry point for symptom screening and temperature check for visitors. Hand sanitizer, surgical masks, and N95 masks made available upon entry. LPA advised to create a symptom screening log and continue the temperature check for all staff prior to the start of their shift. Bathrooms supplied with paper supplies, hygiene products, and hand washing sign. LPA observed facility's supply of PPE. Facility staff have been provided training on infection control. LPA reviewed facility's procedures to isolation, COVID-19 reporting requirements, and visitation. The following signs observed to include social distancing, wear a mask, hand washing, and cough etiquette.

No deficiencies cited per California Code of Regulation, Title 22. Advisory notes provided.

This report was reviewed with Administrator, Annabelle Esperanza and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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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