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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294219
Report Date: 07/07/2021
Date Signed: 07/08/2021 08:02:58 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:2 ALL ABOUT SENIORSFACILITY NUMBER:
435294219
ADMINISTRATOR:KENDALL HALLFACILITY TYPE:
740
ADDRESS:1474 POMPEY DRIVETELEPHONE:
(408) 483-2433
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:6CENSUS: 6DATE:
07/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kendall HallTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Karen Taku conducted an unannounced Case Management visit and met with Administrator (ADM) Kendall Hall.

The purpose of this visit is to assess the facility's request for a total care exception for one resident (R1).

At 3:09pm, LPA interviewed R1 in R1’s room. R1 was observed alert and sitting in a wheelchair watching tv. LPA observed R1 raise left arm. Right & left hand appeared in a stiff fist position (contractures). R1 stated it hurts to feed self. R1 stated R1 has a hard time grabbing utensils. R1 stated R1 can’t do anything for self. R1 stated R1 can only read R1's bible and pray.

LPA reviewed R1’s record during visit. According to R1's physician's report, R1 need assistance with all activities of daily living.

The ADM was informed the Department will review the information and documents obtained during visit.

No deficiencies cited during visit. Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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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