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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200733
Report Date: 10/19/2022
Date Signed: 10/19/2022 11:45:30 AM

Document Has Been Signed on 10/19/2022 11:45 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NIKKO'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
435200733
ADMINISTRATOR:SEDIGH, MALOUFACILITY TYPE:
735
ADDRESS:13540 COLUMBET AVETELEPHONE:
(408) 683-4354
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 6CENSUS: 6DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Malou SedighTIME COMPLETED:
11:48 AM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 10/17/2022. LPA met with facility Administrator Malou Sedigh (Admin).

LPA toured the facility, including living room, kitchen, dining room, laundry room, 6 bedrooms, 3 bathrooms, back patio, back yard yard, activities room. Staff members were not observed wearing masks on entry, but quickly donned them up LPA arrival. Admin confirmed that all staff and residents have been vaccinated.

Facility infectious control plan has already been submitted. No prohibited items noted in resident rooms. 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 June of 2022.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. All restrooms stocked with paper towels. Water temperature observed to be 109.4 degrees Fahrenheit. Hand washing signs observed in all bathrooms. All bathrooms had garbage cans with foot operated lid. Social distancing signs observed to be posted in all public areas. The facility is currently accepting visitors inside the facility, including residents' bedrooms.

No deficiencies cited during visit. Advisory notes issued. This report was reviewed with Administrator Malou Sedigh and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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