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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200698
Report Date: 08/16/2024
Date Signed: 08/16/2024 03:57:21 PM

Document Has Been Signed on 08/16/2024 03:57 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:EMBEE MANORFACILITY NUMBER:
435200698
ADMINISTRATOR/
DIRECTOR:		EDNA BAUTISTAFACILITY TYPE:
735
ADDRESS:5867 EMBEE DRIVETELEPHONE:
(669) 234-3601
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Edna Bautista AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 8/16/2024 Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Required-1 year inspection. LPA was greeted by 2 staff (S1 and S2) and a resident (R1), administrator (ADM) Edna Bautista was not present but was called by S1 and arrived 10 minutes after the call. LPA stated the purpose of the visit with S1, S2 and ADM.

This facility is licensed to serve adults that are developmentally disabled (Level 4C). The facility's capacity is 6, however, the current census is 5.

At 1:20 p.m. LPA entered facility and observed 1 resident (R1) in the living room and spoke with LPA. 4 of 5 resident were in the day program. LPA with S1 toured the facility inside and outside, including but not limited to the kitchen, dining room, living room, 5 resident room, staff room, garage and laundry room. LPA observed sharps, knives, toxic, cleaning supplies, laundry supplies are not accessible to residents and are in a locked cabinet/drawer.

The facility's room temperature was 78 F degrees F. The hot water temperature measured at 108.8 degree F up to 110.2 degree F. Bathrooms were sanitary, with non-skid mats, and grab bars. LPA observed personal hygiene products (i.e. soap, toilet paper, shampoo) in each bathroom. LPA observed residents' bedrooms to be sanitary, organized and have sufficient storage for resident's personal belongings. Each resident bedroom has an exit door that is free from obstruction. LPA observed the ramp is sturdy and the backyard is maintained and free from any debris.

The facility has 2 days supply of perishable foods and 7 days of nonperishable food. The refrigerator temperature is maintained at 40 degree F, and the freezer is at 0 degree F. The facility has a smoke, carbon monoxide alarm system that is good working condition. First Aid kit is complete and is easily accessible to staff. page 1 of 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: EMBEE MANOR
FACILITY NUMBER: 435200698
VISIT DATE: 08/16/2024
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LPA reviewed 3 of 5 resident record and 3 of 3 staff record. LPA observed records are, complete and up to date. The Centrally Stored Medication and Destruction Record (CSMDR) was reviewed and observed to be up to date. Staff have criminal record clearances and received sufficient training for types of residents served. Staff have current first aid/CPR training.

The facility is equipped with fire extinguisher which was last inspected on 5/16/2024.

LPA requested the following documents: LIC 500, resident roster, LIC 308, updated surety bond and updated administrator certificate and was received during today's inspection.

No deficiency(s) were cited during today's inspection based on California Code of Regulations (CCR). An exit interview was conducted with administrator Edna Bautista and a copy of the report was provided.

end of report
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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