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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201781
Report Date: 03/22/2024
Date Signed: 03/22/2024 03:35:38 PM

Document Has Been Signed on 03/22/2024 03:35 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: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:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Assistant Nilda BautistaTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Assistant (AA) Nilda Bautista. During the visit, LPA observed 2 residents and 2 staff.

LPA toured the facility inside out with AA which included the Living room, kitchen, dining room, 2 restroom and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. LPA observed the two storage units in the backyard being used as storage units. There was no obstruction to block the walkways.

While touring the facility, LPA observed bedroom #1's sliding screen door was damaged in the bottom portion. LPA also observed the family room's sliding screen door was missing. AA stated they are being replaced, and have already ordered the sliding door screens for the all bedrooms.

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 71 degrees F, and hot water temperature was measured at 107 degrees F in resident bathroom.

Fire extinguisher was serviced in October 11, 2023. The facility was equipped with 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 February 3, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 1 resident.

No deficiencies cited. A technical violation was given during today's visit. This report was reviewed with Administrator Assistant Nilda Bautista and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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