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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294258
Report Date: 10/25/2022
Date Signed: 10/25/2022 04:25:40 PM


Document Has Been Signed on 10/25/2022 04:25 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:BECK CARE HOMEFACILITY NUMBER:
435294258
ADMINISTRATOR:ZHANG, YU & LUO, XI-HUAFACILITY TYPE:
740
ADDRESS:1681 BECK DRIVETELEPHONE:
(408) 866-7858
CITY:SAN JOSESTATE: CAZIP CODE:
95130
CAPACITY:6CENSUS: 6DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Xi-Hua LuoTIME COMPLETED:
11:33 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Xi-Hua Luo. Upon arrival, Staff Abigail Daz (S1) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside and out with ADM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, dinning room and five restrooms were inspected. One trash cans was observed without cover. ADM stated ADM will replace the trash can with cover today. Cloth towels were observed in kitchen. Paper towels were observed with holders. Six single resident bedrooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 70 degree F, and hot water temperature was at 106 degree F in facility. Six residents and 3 staff were observed in facility.

Fire extinguisher was serviced on 08/15/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated and done with booster. ADM stated the facility already submitted the Infection Control Plan to CCL office. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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