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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200281
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:53:47 PM


Document Has Been Signed on 04/21/2022 04:53 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:DRY CREEK GUEST HOMEFACILITY NUMBER:
435200281
ADMINISTRATOR:IGNACIO, ESTHER L.FACILITY TYPE:
740
ADDRESS:1856 DRY CREEK ROADTELEPHONE:
(408) 559-6010
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 0DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Esther IgnacioTIME COMPLETED:
11:01 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Esther Ignacio. Upon arrival, Staff Ven Ignacio (VI) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out with VI. Wearing mask posters were observed at main door. No other COVID signage and no screening station were observed at main entrance. VI stated the facility has been without residents for more than one year. VI stated the facility is trying to accept residents, but still cannot get any residents. There are 6 resident bedrooms, 1 staff live-in room, and 6 restrooms in facility. The facility is in non operational now. VI is the husband of ADM.

Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated both VI and ADM are fully vaccinated and done with booster. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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