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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294254
Report Date: 12/28/2022
Date Signed: 12/28/2022 05:19:53 PM


Document Has Been Signed on 12/28/2022 05:19 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: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: 6DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:47 PM
MET WITH:Administrator, Sufen WuTIME COMPLETED:
05:30 PM
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On 12/28/2022 at 3:47pm, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual inspection focusing on infection control. LPA met with Administrator (ADM) Sufen Wu.

During visit, LPA Rai toured the facility to include the family room, 5 resident rooms, 2 bathrooms, 1 staff room, kitchen, laundry area, dining area and exterior. All fire exit routes are free and clear of obstruction. LPA Rai observed 3 residents in the living room and 3 residents in their rooms.

Facility observed to have a designated central entry point to include a sign-in sheet and temperature check. Facility clean and disinfect twice daily and as often as needed. Bathrooms supplied with hygiene products and hand washing sign. Trash can with lid observed. LPA observed gowns and gloves by the front door but not sufficient amount of Personal Protective Equipment (PPE) for 30 days. ADM will obtain more supplies and keep in the supply closet. Hand washing signs were observed to be in all bathrooms.

The following posters observed to include wash your hands, symptoms of COVID-19, and importance of wearing a mask.

LPA Rai observed a no visitor sign posted at the front door. Administrator removed the no visitor sign during visit. LPA Rai advised of the visitation guidelines per PIN 22-28.1-ASC.

No deficiencies were cited per California Code of Regulations, Title 22. Technical Assistance Note was provided.

This report was reviewed with Administrator Sufen Wu 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: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
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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