<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200793
Report Date: 04/25/2022
Date Signed: 04/25/2022 04:41:09 PM

Document Has Been Signed on 04/25/2022 04:41 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:NIKKO'S RESIDENTIAL CARE HOME IIFACILITY NUMBER:
435200793
ADMINISTRATOR:VILLAREAL, MICHELLEFACILITY TYPE:
735
ADDRESS:5724 BLOSSOM AVETELEPHONE:
(408) 972-1792
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Jhanelle GuicoTIME COMPLETED:
04:45 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) Christine Dolores arrived unannounced to conduct the annual inspection to focus on infection control. LPA met with Direct Support Personnel, Ligaya Sicat and Direct Support Personnel, Jhanelle Guico.

During visit, LPA toured the facility to include the living room, dining room, kitchen, resident rooms, bathrooms, laundry room, and backyard.

Facility has a designated entry point for COVID-19 symptom screening for residents, staff, and visitors. Bathrooms observed to be supplied with hygiene products, paper supplies, and hand washing signs. Facility has foot operated trash cans with lid. LPA observed supply of Personal Protective Equipment (PPE). Facility staff has ordered additional PPE supplies to include gloves. Facility is cleaning and disinfecting multiple times daily and as needed. All residents has their emergency contact information located in their binder.

The following signs were observed to include social distancing, required mask, stop the spread of germs, feeling sick, and donning and doffing PPE. All staff observed to be wearing a face mask.

The following documents were requested to include an updated LIC-610C and Emergency Evacuation Plan by 04/27/2022. LPA informed staff to submit Infection Control Plan to CCLD by 06/30/2022 and review PIN 22-13-ASC.

No deficiencies issued per the California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Direct Support Personnel, Jhanelle Guico and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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 1