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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201943
Report Date: 03/23/2022
Date Signed: 03/23/2022 01:58:26 PM

Document Has Been Signed on 03/23/2022 01:58 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:CCC ARF INC. DBA NANTUCKET HOME 3FACILITY NUMBER:
435201943
ADMINISTRATOR:MARIA VALENTINA CRISTOBALFACILITY TYPE:
735
ADDRESS:2334 OAK FLAT ROADTELEPHONE:
(408) 923-2933
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: 3DATE:
03/23/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria Valentina CristobalTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager Romeo Manzano, and Nurse Lori Kopplinger conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Maria Valentina Cristobal.

Administrator Cristobal reports that there are currently 0 COVID-19 positive residents and 0 COVID-19 positive staff.

During today's tele-visit, the following recommendations were made to the facility by Nurse Lori Kopplinger:

1. Facility needs to implement a screening log to record visitor and staff symptoms and temperatures.
2. Place hand washing sign in bathroom stating to wash hands for at least 20 seconds.
3. Obtain PPE cart for facility's sole use.
4. Have staff fit tested for N95 masks.
5. Have a 30-day supply of PPEs, including N95 masks.

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with with Administrator Cristobal. A copy of the report will be sent to her for it be signed and returned to CCL.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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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