<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201889
Report Date: 05/31/2022
Date Signed: 05/31/2022 12:26:51 PM

Document Has Been Signed on 05/31/2022 12:26 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:TWELVEACRES BUCKNALL HOMEFACILITY NUMBER:
435201889
ADMINISTRATOR:AMY HELLYERFACILITY TYPE:
735
ADDRESS:5147 BUCKNALL ROADTELEPHONE:
(408) 341-0400
CITY:SAN JOSESTATE: CAZIP CODE:
95130
CAPACITY: 6CENSUS: 4DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Muthoni MachariaTIME COMPLETED:
12:28 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 05/31/2022 at 11:05am. LPA met with facility house manager Muthoni Macharia (Admin).

LPA toured the facility, including living room, activity room, kitchen, dining room, office, laundry room, garage, 4 resident bedrooms, 2 bathrooms, and back yard. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

Facility Mitigation plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to have been inspected in July 2021. All cleaning supplies and chemicals noted to be in locked cabinets and closets. Smoke/carbon monoxide detectors were tested and observed to be operational.

Facility observed to have a designated entry point. Staff took LPA's temperature and screened for symptoms. 30 days supply of PPE was not observed, as the facility did not have surgical gowns. Hand washing signs were observed in the facility bathrooms. Water temperature observed to be 116.6 *F in facility bathroom. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. Report was reviewed with facility house manager Muthoni Macharia and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3