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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201586
Report Date: 05/23/2024
Date Signed: 05/23/2024 11:14:14 AM

Document Has Been Signed on 05/23/2024 11:14 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SANDY'S RCH - REDMONDFACILITY NUMBER:
435201586
ADMINISTRATOR/
DIRECTOR:		ZIPAGAN, SANDYFACILITY TYPE:
735
ADDRESS:1065 REDMOND AVENUETELEPHONE:
(408) 472-2059
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY: 6CENSUS: 6DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Sandy Zipagan Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 05/23/2024 at 8:01 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived and conducted an unannounced required 1 year inspection visit. LPA was greeted by 2 staff and the administrator (ADM) Sandy Zipagan. LPA stated the purpose of the visit to ADM.

The facility is a Adult Residential Facility (ARF) licensed to serve (6) developmentally disabled adults 18-59 years old. All of whom can be non-ambulatory and the facility is approved for 2 hospice waiver for residents. 2 staff were present at the time of the visit. 6 out 6 residents was getting ready to go to the day program at the time of the visit.

At 8:10 a.m. LPA toured the facility inside and outside with ADM, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, backyard, garage and walkways. The temperature inside the home was at 68 to 69.8 degrees F.

LPA and ADM toured the 4 rooms, 3 out of 4 rooms are used by residents and 1 out of 4 rooms are used as a staff room. LPA observed 2 bathroom 1 out of 2 is currently under repair. LPA inspected the permitted Additional Dwelling Unit (ADU) at the back of the house. ADM stated the ADU will be used as staff dwelling no resident will be housed in the ADU. The ADU has full kitchen, bathroom, laundry area, living area, 1 bedroom and closet. LPA observed 3 out of 3 resident rooms are shared. LPA observed rooms to be organized, sanitary and free from any debris and has sufficient storage for residents' personal belongings. LPA observed that 3 out 3 bedroom has sliding door that easily opens and are free from obstruction.

LPA observed that the facility has smoke and carbon monoxide alarm that are in good working condition. LPA observed hallways, ramps and walkways are free from obstruction. LPA observed the backyard area to be free from debris and is well maintained.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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: SANDY'S RCH - REDMOND
FACILITY NUMBER: 435201586
VISIT DATE: 05/23/2024
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LPA with ADM toured 1 bathroom and LPA observed the bathroom have anti skid mats and grab bars and with sufficient supply of paper towels and toiletries. LPA observed residents room are free from debris, maintained and organized.

LPA tested the water temperature for kitchen is at 122.1 degree F and the bathroom water temperature is at 120 degree F. The facility has sufficient supply of perishable food for 2 days and non-perishable food for 7 days. LPA observed knives are in a locked drawer not accessible to residents. The fire extinguishers was inspected on 6/2/2023. First aid kit is complete and up to date.

LPA and ADM inspected the laundry area located inside the garage and are in good working condition. Cleaning supplies and detergents were separated and in a locked cabinet. LPA observed the medication cabinet is locked and is not easily accessible. LPA observed first aid kit to be complete and easily accessible.
LPA reviewed facility record, 2 staff record and 3 out of 6 resident record. Facility's fire drill training conducted on 03/4/2024. The facility records are up to date. Staff training records were up to date. Staff records were reviewed with current first aid certifications, clearance and training. Residents files were reviewed to be complete. Residents' medications are labeled and current.

LPA requested for the update of the following: Surety Bond, LIC 500, LIC 308, Emergency Disaster Plan & resident roster.

No Deficiencies are cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with ADM Sandy Zipagan, a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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