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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201495
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:49:02 PM

Document Has Been Signed on 11/15/2024 12:49 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:NANTUCKET HOMEFACILITY NUMBER:
435201495
ADMINISTRATOR/
DIRECTOR:
CRISTOBAL, MARIAFACILITY TYPE:
735
ADDRESS:1559 QUEENS CROSSING DRIVETELEPHONE:
(408) 926-6416
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Maria CristobalTIME VISIT/
INSPECTION COMPLETED:
12:48 PM
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced annual inspection visit, and met with Maria Cristobal. During the visit, LPA observed 3 staff and 0 resident they were attending day program. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM included the Living room, kitchen, dining room, 3 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways and ramps.

LPA observed two day perishable food supplies and seven day nonperishable food supplies. Refrigerator measured at 40 degrees F and 0 degrees F in freezer. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature in Bathroom was measured with thermometer at 116.6 degrees F. Kitchen sink was measured with thermometer at 115.1 degrees F.

While touring the facility LPA observed a locked shed that is being used for storage and not as a living space.

Fire extinguisher was serviced in 09/20/2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 08/19/24

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. P & I was also audited. LPA conducted interviews with 2 staff and no resident interview 6 out of 6 residents at day program.

No deficiencies cited during today's visit. This report was reviewed with Maria Cristobal (ADM) and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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