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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200397
Report Date: 04/06/2022
Date Signed: 04/06/2022 11:22:40 AM

Document Has Been Signed on 04/06/2022 11:22 AM - 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 IIIFACILITY NUMBER:
435200397
ADMINISTRATOR:ROGER CADAYFACILITY TYPE:
735
ADDRESS:3033 STEVENS LANETELEPHONE:
(408) 440-0741
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 4DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Cecilia CadayTIME COMPLETED:
11:23 AM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 04/06/2022. LPA met with facility staff member Cecilia Caday (S1). Administrator Roger Caday (Admin) was at the doctor's office with a facility resident, and was unable to attend the inspection. Admin gave S1 permission to lead the inspection in his stead.

LPA toured the facility, including living room, kitchen, dining room, 5 bedrooms, 2 bathrooms, garage, 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 emergency exits noted to be clear of obstruction. 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 extinguishers observed to be inspected in February 2022. Smoke detectors tested and observed to be fully operational.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. Facility observed to have a thirty day supply of PPE on the premises. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. Both bathrooms observed to have had lidded trash cans.

Water temperature observed to be 136.5 *F, which is 16.5 degrees over the maximum.

Deficiency cited during today's visit. See 809-D. This report was reviewed with facility staff member Cecelia Caday and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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Document Has Been Signed on 04/06/2022 11:22 AM - It Cannot Be Edited


Created By: Ryker Heberle On 04/06/2022 at 11:06 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CADAY ADULT RESIDENTIAL FACILITY III
FACILITY NUMBER: 435200397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
80088(e)(1) Furniture, Fixtures, Equipment, and Supplies - (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as the water temperature was observed to be 136.5 degrees F, 16.5 degrees above the acceptable limit, this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Licensee to adjust the water temperature to be within the compliant range and provide photographic and/or video proof of the correction by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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