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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201809
Report Date: 07/22/2021
Date Signed: 02/28/2022 04:10:55 PM

Document Has Been Signed on 02/28/2022 04:10 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:BLUE SKY RESIDENTIAL CARE HOMEFACILITY NUMBER:
435201809
ADMINISTRATOR:VICTORIA ALEJANDROFACILITY TYPE:
735
ADDRESS:4040 BRIARGLEN DR.TELEPHONE:
(408) 314-3253
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 6DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Reza FarakeshTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Karen Taku conducted an unannounced annual (Infection Control) Inspection today. LPA met with Administrator (ADM) Reza Farakesh.

At 3pm, LPA entered the facility through the designated entry point and was greeted by Staff. COVID-19 screening station observed at the facility's designated entry point.

At 3pm, LPA was accompanied by Staff and the ADM during a tour of the facility, inside and out. All restrooms were observed with handwashing posters, liquid soap, paper towels, and a touchless garbage can. COVID-19 prevention posters were observed in the main dining/living room area of the facility. LPA observed an adequate supply of PPE readily available to staff. Backyard/patio area observed in good repair.

LPA obtained copies of the following documents during visit:

1. LIC 500- Personnel Summary
2. LIC 308- Designation of Administrative Responsibility
3. LIC 610- Emergency Disaster Plan
4. Current Administrator's Certificate

The facility is adhering to the COVID-19 Mitigation Plan approved on 3/22/21.

No deficiencies were cited. Exit interview conducted with the ADM and a copy of this report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Karen Taku
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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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