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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294272
Report Date: 03/09/2022
Date Signed: 03/11/2022 10:21:07 AM


Document Has Been Signed on 03/11/2022 10:21 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:CARING HEARTS SENIOR CARE HOME, INCFACILITY NUMBER:
435294272
ADMINISTRATOR:VELASQUEZ, OLIVIAFACILITY TYPE:
740
ADDRESS:3065 VAN SANSUL AVENUETELEPHONE:
(408) 296-7081
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:12CENSUS: 11DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Gilson ValerioTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection. LPA met with Assistant Administrator, Gilson Valerio.

During today's visit LPA toured the facility inside and outside. LPA observed a central entry point and screening area for all visitors and staff. Hand sanitizer available upon entry. All fire exit routes were free and clear of obstructions. Medications are stored in locked closet. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products and paper supplies. Hand washing signs were posted in bathrooms and throughout facility. Hand sanitizer available to residents and visitors. LPA observed supply of Personal Protective Equipment (PPE). Staff are trained on donning and doffing PPE. All staff observed to be wearing a face mask.

LPA observed the following posters to include cough etiquette, required mask, keep facility clean, and droplet precaution. Facility disinfect and sanitize high touch surfaces daily and as needed.

No deficiencies cited during today's visit per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Assistant Administrator, Gilson Valerio and a copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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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