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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201781
Report Date: 03/30/2022
Date Signed: 03/30/2022 04:49:32 PM

Document Has Been Signed on 03/30/2022 04:49 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:NANTUCKET HOME 2FACILITY NUMBER:
435201781
ADMINISTRATOR:CRISTOBAL, MARIAFACILITY TYPE:
735
ADDRESS:2055 ADMIRAL PLACETELEPHONE:
(408) 347-1744
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 3DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tina Cristobal, ADMTIME COMPLETED:
02:28 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Tina Cristobal. Upon arrival, staff Edelinov Galingana (EG) took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with EG. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, glove, thermometer and visitor log book was observed at the main entrance. Living room, family room, kitchen, dinning room and two restrooms were inspected. Some trash cans were observed without covers. EG stated the facility will replace the trash cans with covers. Paper towel were observed with holders. Cloth towels were observed in kitchen. EG removed the cloth towel in kitchen. Three single resident bedrooms, and laundry room were inspected. One staff live-in room is in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 69 degree F, and hot water temperature was at 109 degree F in facility. Two residents and 3 staff were observed in facility.

Fire extinguisher was serviced on 10/28/2021. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by EG, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated and done with booster. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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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