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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201149
Report Date: 10/27/2021
Date Signed: 10/27/2021 04:16:36 PM

Document Has Been Signed on 10/27/2021 04:16 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:BAYMILL CARE HOME IIFACILITY NUMBER:
435201149
ADMINISTRATOR:LOLITA BAUTISTAFACILITY TYPE:
735
ADDRESS:2065 DANDERHALL WAYTELEPHONE:
(408) 440-0433
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:LOLITA BAUTISTATIME COMPLETED:
03:00 PM
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Licensing Program Analyst, Steve Nguyen, conducted an unannounced annual inspection with Administrator LOLITA BAUTISTA.

LPA toured facility inside and out. LPA observed: Covid signs are present and in conspicuous vantage points, are exits are free of obstructions, emergency contact for residents were up to date, facility screening protocols were enforce/ Administrator will train all staff in covid screening protocols, Administrator will ensure that all sink areas will have covid hand washing signs/ paper towels/ mirrors, ensure all outlets are undamaged, hand sanitizing station were available throughout facility, medicine cabinet were observed to be locked, paper towers are in use, all beds in facility are at least 6 feet apart/ in a head to toe configuration, and physical distancing was observed to be in practice.

No citation was issued at this time.

LPA went over report findings with Administrator, LOLITA BAUTISTA, for review and a copy was provided
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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