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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430702974
Report Date: 07/06/2022
Date Signed: 07/06/2022 12:08:00 PM


Document Has Been Signed on 07/06/2022 12:08 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:ESTHER'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
430702974
ADMINISTRATOR:IGNACIO, ESTHERFACILITY TYPE:
740
ADDRESS:1224 BENT DRIVETELEPHONE:
(408) 559-0681
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:6CENSUS: 6DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Esther IgnacioTIME COMPLETED:
12:10 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 07/06/2022 at 10:57am. LPA met with facility Administrator Esther Ignacio (Admin).

LPA toured the facility, including living room, kitchen, office, garage, 6 resident bedrooms, 3 bathrooms, and back yard. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

Facility Mitigation plan has already been submitted. No prohibited items noted in resident rooms. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to have been inspected in April of 2022. All cleaning supplies and chemicals noted to be in locked cabinets and closets. Smoke/carbon monoxide detectors were tested and observed to be operational.

Facility observed to have a designated entry point. Staff took LPA's temperature and screened for symptoms. 30 days supply of PPE was observed. Hand washing signs were observed in the facility bathrooms. Water temperature observed to be 116.6 *F in facility bathroom. Facility temperature observed to be 75*F. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. Report was reviewed with Administrator Esther Ignacio and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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