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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201527
Report Date: 12/20/2023
Date Signed: 12/26/2023 08:28:34 AM

Document Has Been Signed on 12/26/2023 08:28 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
Lookup Error,
, CA
FACILITY NAME:CAPRI HOME IIFACILITY NUMBER:
435201527
ADMINISTRATOR:GANIYU AJANIFACILITY TYPE:
735
ADDRESS:324 SAN ANDREAS COURTTELEPHONE:
(408) 586-8476
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 3CENSUS: 3DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Ajani Ganiyu, Licensee/Administrator TIME COMPLETED:
01:15 PM
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On 12/20/23, Licensing Program Analysts (LPA) L. Salazar and LPA Doucette arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPAs were greeted by staff, stated the purpose of the visit and was allowed entry into the facility. Administrator arrived to the facility a few minutes later. Staff provided a tour of the facility inside and out. Administrator on record is Ajani Ganiyu, Certificate #6017933735 Expires 09/2024.

LPA observed 1 resident in care at the time of visit. Facility is a 6 bedroom 2 bathroom home. Resident's have their own bedrooms and there are 6 live in staff. Resident rooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. Facility temperature was 68 degrees F.

Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 111.1 degrees F. Covered trash can with lid and hand washing postings were observed.

Medications were observed to be locked in a kitchen cabinet . Cleaning supplies were observed to be locked under the kitchen sink. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. There are no residents with Restricted Health conditions in the facility.
Carbon monoxide and smoke detectors were tested and observed to be operational. Night lights were observed in the hallways. Fire Extinguisher was observed with a service date of 10/23/23. First aid kit was observed and contained all required items.

The exterior tour of back yard was conducted and found to be free from debris. A covered outdoor seating area was observed available for residents in care. Side gate was self-closing and self-latching.

(Continued on LIC 809-C)
SUPERVISORS NAME: Melinda Medina
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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
Lookup Error,
, CA
FACILITY NAME: CAPRI HOME II
FACILITY NUMBER: 435201527
VISIT DATE: 12/20/2023
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(Continued from LIC 809)

A sample of resident files were reviewed and observed to have update emergency contacts, Admission agreement, and current physician report/individual performance plans (IPP). Staff files were also reviewed and observed to have current First Aid/CPR, and required forms. Staff are fingerprinted clear and associated to the facility.

Quarterly Emergency Disaster Drill logs were observed on 11/08/23 for staff. LPA observed on the LIC 610D (Emergency Disaster Plan) with emergency numbers and evacuations locations was posted in the entry.

An exit interview was conducted with Licensee. No deficiencies cited on today's visit.
SUPERVISORS NAME: Melinda Medina
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
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