<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294300
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:31:55 AM


Document Has Been Signed on 04/29/2022 11:31 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:APRIL GARDEN VILLA OF SARATOGAFACILITY NUMBER:
435294300
ADMINISTRATOR:TAN, THELMAFACILITY TYPE:
740
ADDRESS:12226 PLUMAS DRIVETELEPHONE:
(408) 777-8043
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:5CENSUS: 4DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Thelma TanTIME COMPLETED:
11:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control and met with Administrator, Thelma Tan.

During visit, LPA toured the facility to include the living room, dining room, resident rooms, bathrooms, and kitchen. All fire exit routes are free and clear of obstruction. Medications observed in a locked cabinet.

Facility has a designated entry point for COVID-19 symptom screening for all visitors and staff. Hand sanitizer available upon entry. Bathrooms supplied with paper supplies, hygiene products, and hand washing sign. LPA observed a trash can covered with lid. LPA observed facility's supply of Personal Protection Equipment (PPE). LPA reviewed facility's policies and procedures to isolation. Facility clean and disinfect multiple times daily and as needed. Staff monitor residents temperature and symptoms daily. All staff and residents are fully vaccinated and boosted. All staff observed to be wearing a face mask. The following posters were observed to include symptoms of COVID, cough etiquette, and protect yourself from COVID.

No citations were issued per the California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Thelma Tan and a copy of the report will be emailed due to printer issues.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3