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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200974
Report Date: 03/12/2024
Date Signed: 03/17/2024 07:53:21 PM


Document Has Been Signed on 03/17/2024 07:53 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:CHURCH RCFFACILITY NUMBER:
435200974
ADMINISTRATOR:ZIPAGAN, AZUCENAFACILITY TYPE:
740
ADDRESS:1306 CHURCH AVENUETELEPHONE:
(408) 686-0751
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:6CENSUS: 6DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Azucena ZipaganTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual inspection visit and met with Administrator (ADM) Azucena Zipagan.

The facility has 6 resident and 3 staff including the administrator. All residents are currently out of the facility attending day program at the time of the visit.

LPA observed the following are displayed prominently and can be easily seen; facility license, personal rights, administrator certificate and visitor hours posters were observed at the main entrance. LPA toured the exterior and interior of the facility with the staff (S1), Assistant Administrator (AADM) and ADM. LPA inspected living room, kitchen, dinning area, restrooms, laundry room and garage. The facility has 4 resident bedrooms, 3 restrooms, 1 staff room.

LPA observed medication, knives and toxic materials including but not limited to laundry detergents are observed in a locked cabinet not easily accessible. Non-skid mats and handle bars were observed in bathrooms. Room temperature was observed at 68 to 76 degree Farenheit (F) and water temperature in the bathroom and kitchen measured from 110 to 120 degree F.

Refrigerator temperature was measured at 35 degree F, freezer temperature was measured at negative 10 degree F. LPA observed food supply is ample/sufficient for 2 days of perishable and 7 days non-perishable.

Continued on LIC 809C
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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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: CHURCH RCF
FACILITY NUMBER: 435200974
VISIT DATE: 03/12/2024
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LPA observed the facility is equipped with fire alarm, fire sprinklers, carbon monoxide and smoke detector. Smoke alarm and carbon monoxide detector were tested and were found in good working condition.
The fire extinguishers complies with the Fire Marshall's requirement. The interior hallways have working night lights.

LPA observed the outside perimeter, ramps and walkways were free from any obstruction and debris.
LPA reviewed 3 residents and 2 staff records. The records were complete and updated for the residents. The staff records were updated.

No deficiencies and citations were issued for today's visit per California Code of Regulations Title 22. The exit interview was conducted with ADM Azucena Zipagan and signed copy of the report were provided to ADM.

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End of Report
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2