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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201587
Report Date: 11/15/2024
Date Signed: 11/15/2024 09:42:21 AM

Document Has Been Signed on 11/15/2024 09:42 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:FITZGERALD RCHFACILITY NUMBER:
435201587
ADMINISTRATOR/
DIRECTOR:
ZIPAGAN, SANDYFACILITY TYPE:
735
ADDRESS:965 FITZGERALD AVE.TELEPHONE:
(408) 847-4947
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 6CENSUS: 6DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Sandy ZipaganTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Sandy Zipagan. During the visit, LPA observed 0 residents and 2 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 4 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. LPA toured the garage, which is being used as a storage space for to vehicles and general storage. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. 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 75 degrees F, and hot water temperature was measured at 112 degrees F in resident bathrooms.

Fire extinguisher was serviced in June 5, 2024. The facility was equipped with a centralized sprinkler system. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on November 10, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA's reviewed 3 resident P&I records. LPA conducted interviews with 1 staff. Residents were attending day program during LPA's visit.

No deficiencies cited during today's visit. This report was reviewed with Administrator Sandy Zipagan and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
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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