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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200831
Report Date: 06/14/2024
Date Signed: 06/14/2024 03:31:50 PM

Document Has Been Signed on 06/14/2024 03:31 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:TWELVEACRES-BRAEBURN HOMEFACILITY NUMBER:
435200831
ADMINISTRATOR/
DIRECTOR:
AMY HELLYERFACILITY TYPE:
735
ADDRESS:3950 BRAEBURN COURTTELEPHONE:
(408) 984-7237
CITY:SAN JOSESTATE: CAZIP CODE:
95130
CAPACITY: 6CENSUS: 4DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Amy HellyerTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Amy Hellyer.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area. LPA Marrufo observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. There were locked drawers for sharps and cleaning supplies. The first aid kit was reviewed and found to be complete.

LPA Marrufo tested the smoke detectors in the hallway and four out of four bedrooms. Each smoke detector functioned properly when tested. The resident bedrooms had functioning lights and available bedding and clothing storage areas.

LPA toured three out of three resident bathrooms and observed the water temperatures to be between 114 F and 118 F. Each bathroom had functioning lights and available soap and paper towels.

The outside area was toured and the outside exit was observed to be clear of obstructions.

LPA reviewed the Personal and Incidental Money Logs for 4 out of 4 residents and found them to be balanced. LPA Marrufo reviewed 4 out of 4 resident records and 5 staff records and found them to be complete.

The Earthquake and Fire Drill Log indicates the last recorded drill was conducted on 06/06/2024.

No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Amy Hellyer and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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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