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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294254
Report Date: 12/22/2021
Date Signed: 12/23/2021 08:31:25 AM

Document Has Been Signed on 12/23/2021 08:31 AM - It Cannot Be Edited

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:CONNLY CARE HOMEFACILITY NUMBER:
435294254
ADMINISTRATOR:SUFEN WUFACILITY TYPE:
740
ADDRESS:1547 KOOSER ROADTELEPHONE:
(408) 445-1228
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 4DATE:
12/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sufen WuTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 12/22/2021 at 09:45am. LPA met with facility Administrator Sufen Wu (Admin).

LPA toured the facility, including living room, kitchen, family room, 4 client bedrooms, 1 staff bedroom, back yard, and garage. Staff members observed to not be wearing masks upon LPA arrival. LPA reminded Admin that staff is to wear masks at all times. Admin confirmed that all staff and residents have been vaccinated.

Facility observed to have designated entry point. Staff took LPA's temperature but did not screen for symptoms. Facility did not have gowns or face shields, but was otherwise observed to have a 30 day supply of PPE. Restrooms were stoked with paper towels. Hand washing signs were observed to be in all bathrooms. Social distancing signs observed to be posted in all public areas. The facility is currently accepting visitors inside the facility, including residents' bedrooms.

LPA observed medication on a resident's night stand. Admin explained to LPA that they had been giving the resident medication along with their lunch. A bowl of applesauce was noted next to medicine on night stand. LPA reminded Admin to store medication after administration. Admin stated that she understood and placed the medication back inside the medicine cabinet. All rooms in facility noted to be clean and odorless. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. LPA observed rotting fruit in kitchen, dining room, and backyard. LPA also observed fruit flies and ants in the kitchen and dining room.

Deficiency was cited during today's visit. See 809-D. This report was reviewed with Administrator Sufen Wu and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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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Document Has Been Signed on 12/23/2021 08:31 AM - It Cannot Be Edited


Created By: Ryker Heberle On 12/22/2021 at 11:21 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CONNLY CARE HOME
FACILITY NUMBER: 435294254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555
87555 - General Food Service Requirements - (b) The following food service requirements shall apply:
(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above by having visible rotting fruit and insects in the kitchen and dining room area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2021
Plan of Correction
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Licensee is to perform an audit of the facility food storage and dispose of all spoiled foods and contact an exterminator to clear insects. Licensee shall submit proof of extermination service and food audit plan to The Department by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
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