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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201149
Report Date: 10/28/2022
Date Signed: 10/28/2022 11:57:49 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/28/2022 11:57 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
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: 6DATE:
10/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:LOLITA BAUTISTATIME COMPLETED:
10:39 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) LOLITA BAUTISTA. Upon arrival, Staff Victoria Lauder (S1) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside and out with S1. COVID posters were observed at main entrance. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Living room, office, kitchen, dinning room and two restrooms were inspected. Trash cans were observed with covers. Some paper towels were observed without holders. ADM stated the facility will put all the paper towers with holders in 3 days. Cloth towels were observed in restrooms. Posters of washing hands were observed in kitchen and restrooms, but no posters of washing hands for 20 seconds were observed in restrooms and kitchen, ADM stated ADM will put the posters of washing hands for 20 seconds by the sinks in kitchen and restrooms in 3 days. Four resident bedrooms, and laundry room were inspected. One staff live-in room was observed in the facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 70 degree F, and hot water temperature was at 107 degree F in facility. 6 residents went to day program. Two staff were observed in facility.

The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the staff and residents were fully vaccinated and done with boosters. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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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