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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707449
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:40:54 PM

Document Has Been Signed on 02/18/2022 03:40 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:CADAY ADULT RESIDENTIAL FACILITY #2FACILITY NUMBER:
430707449
ADMINISTRATOR:CADAY, ELLIEFACILITY TYPE:
735
ADDRESS:268 KETCHUM DR.TELEPHONE:
(408) 770-2210
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Ellie Caday, ADMTIME COMPLETED:
03:37 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with administrator (ADM) Ellie Caday, and House Manager (HM) Olivia Lazo. Upon arrival, HM took LPA body temperature and checked LPA into the guest book. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. COVID posters were observed at the main entrance and in facility. 2 staff and 4 residents were observed in facility.

LPA toured the facility inside out with HM. LPA inspected living room, kitchen, dinning area, and laundry room. Medication closet, knives closet, and cleaning product closet were observed locked. There are 4 rooms for residents, and one staff live-in room in facility. 3 bathrooms are in facility. Paper towels were observed with holders, Cloth towels were observed in restrooms. HM removed the cloth towel in restroom. Trash cans were observed with covers. Room temperature was observed at 69 degree F, and hot water temperature was observed at 113 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. HM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 03/13/2021. LPA inspected the backyard, there was no obstruction to block the walkway.

ADM stated all staff and residents are fully vaccinated and done with booster.

No deficiency or issue noted during inspection. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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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