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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202293
Report Date: 06/09/2021
Date Signed: 06/30/2021 09:35:05 AM

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:KB CARE HOMEFACILITY NUMBER:
435202293
ADMINISTRATOR:KAITLYN BROWNELLFACILITY TYPE:
735
ADDRESS:1948 SEABEE PLACETELEPHONE:
(408) 823-6734
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY:6CENSUS: 5DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Gina Montorio / Kaitlyn BrownellTIME COMPLETED:
11:50 AM
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On 06/09/2021 at 9:15 am, Licensing Program Analyst (LPA) Anna Bui and Licensing Program Manager (LPM) Sarah Yip conducted an unannounced Annual Required 1 Year visit. LPA and LPM met with staff Gina Montorio. Administrator Kaitlyn Brownell joined LPA and LPM at the end of the tour.

LPA and LPM toured the facility beginning with the main entrance. The entrance had a thermometer, hand sanitizer, and sign-in log to document temperature. No screening questions were asked or documented. LPA recommended screening questions to be asked and documented. ADM provided a COVID-19 screening questions log while LPA and LPM were still present at the facility.

Universal precautions, COVID-19 protocols, and social distancing guidelines were posted throughout the facility. Restrooms had hand soap and towels readily available. Hand washing sign was posted at all hand washing stations. 1 out of 2 restrooms had a trash can with a lid and foot pedal. LPA recommended a trash can with a lid and foot pedal for the shared bathroom.

Staff were observed wearing a mask and following COVID-19 protocols. Facility observed to have adequate supply of PPE.

No deficiencies were cited during today's visit.

Exit interview was conducted with Administrator Kaitlyn Brownell. This report was reviewed with Administrator Kaitlyn Brownell, and a copy of this report was left with Administrator Kaitlyn Brownell.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna BuiTELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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