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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201781
Report Date: 03/07/2025
Date Signed: 03/07/2025 11:07:29 AM

Document Has Been Signed on 03/07/2025 11:07 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:NANTUCKET HOME 2FACILITY NUMBER:
435201781
ADMINISTRATOR/
DIRECTOR:
CRISTOBAL, MARIAFACILITY TYPE:
735
ADDRESS:2055 ADMIRAL PLACETELEPHONE:
(408) 347-1744
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 3DATE:
03/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Maria Cristobal AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Maria Cristobal Administrator. LPA announced the purpose of the visit. LPA observed 2 staff and 1 resident and 2 resident at day program.

During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. The refrigerator temperature measures with thermometer measured at 30 degrees F and freezer temperature measured at 0 degrees F.

LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. ADM tested the smoke detector found the smoke detector to function properly when tested. LPA toured one resident bathroom. which had available soap and paper towels and functioning lights. The water temperature in the bathroom sink measured with thermometer at 108.1 F.

LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 09/22/24. LPA reviewed Fire and Earthquake log the last fire drill was conducted on 11/09/2024, earthquake drill on 11/10//2024.

LPA observed shed used as storage and not living quarters.

LPA reviewed resident records for 3 resident. LPA reviewed 3 staff records. ADM reviewed Centrally Stored Medication Record and P & I was also reviewed.

No deficiency were cited as per California Code of Regulations Title 22. This report was reviewed with Maria Cristobal Administrator and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2025
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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