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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201710
Report Date: 10/21/2023
Date Signed: 10/22/2023 07:39:23 PM

Document Has Been Signed on 10/22/2023 07:39 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:KERN A.R.F.FACILITY NUMBER:
435201710
ADMINISTRATOR:SASHI KUMARFACILITY TYPE:
735
ADDRESS:2785 KERN AVE.TELEPHONE:
(408) 281-7057
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 4DATE:
10/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Administrator assistant Ernie ManaoisTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Assistant (AA) Ernie Manaois. (LPA observed 1 staff on duty during visit. )

LPA toured the facility inside out with AA which included; the Living room, kitchen, dinning room, 1 resident hallway bathroom, 1 staff bathroom and 3 residents bedrooms. The staff area of the facility was also inspected. 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 cabinet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 76 degree F, and hot water temperature was measured at 108 degrees F in the resident hallway bathroom.

Fire extinguisher was serviced in July 12, 2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by AA, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on September 29, 2023.

LPA reviewed facility records for 2 staff and 2 residents. LPA reviewed 2 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff (S1) and 2 residents (R1-R2). The other two residents were out on an outing.

No deficiencies cited during today's visit. This report was reviewed with Administrator (ADM) Sashi Kumar. ADM stated AA could sign on her behalf. A copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2023
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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