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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201889
Report Date: 05/21/2024
Date Signed: 05/21/2024 04:45:26 PM

Document Has Been Signed on 05/21/2024 04:45 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:TWELVEACRES BUCKNALL HOMEFACILITY NUMBER:
435201889
ADMINISTRATOR/
DIRECTOR:
AMY HELLYERFACILITY TYPE:
735
ADDRESS:5147 BUCKNALL ROADTELEPHONE:
(408) 341-0400
CITY:SAN JOSESTATE: CAZIP CODE:
95130
CAPACITY: 6CENSUS: 4DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Elizabeth MachariaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Elizabeth Macharia.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the facility kitchen area and observed there to be locked drawers and storage areas for sharps and cleaning supplies. The facility first aid kit was inspected and found to be complete. LPA Marrufo observed the food supplies in the kitchen and food storage areas and found there to be a perishable food supply of at least two days and a non-perishable food supply of at least 7 days.

LPA toured two out of two resident bathrooms and found the water temperatures to be 110 F. Each bathroom had working lights and available soap and paper towels.

LPA Marrufo toured three out of three bedrooms. Each bedroom had functioning lights and beds with available bedding and clothing storage areas. LPA Marrufo tested the smoke detectors in each bedroom, in the hallway, and in the living room areas and found each smoke detector to function properly when tested. The carbon monoxide detector functioned properly when tested.

LPA toured the outside area and found the outdoor exits to be clear of obstructions. The Emergency Disaster Drill Log states the last drill was conducted on 04/19/2024.

LPA Marrufo reviewed resident and staff records during visit.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Elizabeth Macharia and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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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