435200157-10-28-2024-26-AS-MPAA-DAGU3J-20241028151337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200157
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:13:58 PM

Document Has Been Signed on 10/28/2024 03:13 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:	SANDY'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	435200157
ADMINISTRATOR/ DIRECTOR:	ZIPAGAN, AZUCENA		FACILITY TYPE:	740
ADDRESS:	550 TUSCARORA DRIVE		TELEPHONE:	(408) 472-2059
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 2	DATE:	10/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Azucena Zipagan - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

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) Maria (Mita) Partoza a conducted an unannounced required 1 year inspection visit and met with licensee/administrator (LIC/ADM) Azucena (Sandy) Zipagan and stated the purpose of the visit. The facility is licensed to serve adults 60 years and over, all may be non-ambulatory, 1 bedridden and waiver for 2 hospice care. 2 Out of 2 residents were out attending day program. At 1:15 p.m. LPA toured the facility inside and outside with ADM including but not limited to the kitchen, bathroom, dining room, living room, 5 residents rooms, garage, backyard and exterior walkways. The temperature inside the home was at 70 degrees Fahrenheit. The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. Under the sink cabinet is used to store cleaning supplies and kept locked and not accessible to residents. The kitchen water temperature measured between 105 to 120 degrees Fahrenheit. The facility is maintained, sanitary and organized. The bathroom/s are equipped with grab bars, non-skid mats. The water temperature in the bathroom measured between 110 to 120 degree Fahrenheit. Resident's room have sufficient storage. LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete and is accessible to staff. page 1 of 2 see LIC 809C

Romeo Manzano	TELEPHONE: (650) 388-2297
Maria Partoza	TELEPHONE: (669) 308-3994
	DATE: 10/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: SANDY'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 435200157
	VISIT DATE: 10/28/2024

NARRATIVE

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The walkways and ramps are free from debris and obstruction. The facility screen windows were observed to be in good repair. The facility has an additional dwelling unit (ADU) that has a separate entrance and address and not connected to the main building. ADM stated that the ADU will be used by staff. The washer and dryer located in the garage and are in good working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care.

The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition, night lights on the hallway are in good working condition. The hallway are free from obstruction. The last fire and drill training was last done in 5/5/2024. Fire extinguisher was last inspected on 6/5/2024.

LPA reviewed 2 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed records to be complete and updated.

LPA reviewed 2 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. All staff have criminal record clearance/fingerprints.

No deficiencies were cited during today's visit. An exit interview was conducted with administrator Azucena Sandy Zipagan. A copy of report was provided.

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end of report

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

LIC809 (FAS) - (06/04)

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