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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201758
Report Date: 08/17/2021
Date Signed: 08/17/2021 04:51:21 PM

Document Has Been Signed on 08/17/2021 04:51 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NEO NICHOLAS MANORFACILITY NUMBER:
435201758
ADMINISTRATOR:CHRISTIA-MARIE MENDOZAFACILITY TYPE:
735
ADDRESS:14961 RIDGETOP DRIVETELEPHONE:
(408) 708-7928
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Christia Mendoza, ADMTIME COMPLETED:
03:52 PM
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At 2:25PM, Licensing Program Analyst (LPA) Steve Chang arrived at facility to conduct the Annual Inspection. Upon arrival at facility, staff Elvira Mones (EM) took LPA body temperature, asked LPA the infection control questionnaires, and checked LPA in the visitor log book. LPA observed the COVID-19 posters in the facility. LPA observed hand sanitizer at many places in the facility. LPA obtained the roster of staff and residents.

LPA toured the facility inside out with EM. LPA met with staff Jesus Cera (S2) and Cemma Gayapa (S3). LPA observed 5 residents (R1 - R5) in facility. There are 3 resident bedrooms, two bathrooms, and one staff room in facility. LPA observed all the trash cans in the bedrooms, bathrooms, kitchen, and common areas have the covers. LPA observed all the staff wore masks in the facility.

LPA observed knives are kept in locked closet, and detergent are locked. LPA observed the medication closet was locked. LPA observed 2 day perishable food and 7 day nonperishable food are sufficient. LPA observed the facility has sufficient PPE supplies.

LPA discussed and reviewed LIC808 with ADM.

No citation were issued during today's inspection. Exit interview conducted with ADM. This report was provided to ADM to review and to sign. A copy of this report was emailed to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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