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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435201943
Report Date:
01/30/2023
Date Signed:
02/06/2023 10:55:48 AM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
02/06/2023 10:55 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:
CCC ARF INC. DBA NANTUCKET HOME 3
FACILITY NUMBER:
435201943
ADMINISTRATOR:
MARIA VALENTINA CRISTOBAL
FACILITY TYPE:
735
ADDRESS:
2334 OAK FLAT ROAD
TELEPHONE:
(408) 923-2933
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95131
CAPACITY:
6
CENSUS:
DATE:
01/30/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:32 AM
MET WITH:
TIME COMPLETED:
09:40 AM
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Licensing Program Analysts (LPAs) Simi Rai and Manuel Monter attempted to do an annual inspection focusing on infection control but no one was at the facility.
SUPERVISORS NAME
:
Romeo Manzano
LICENSING EVALUATOR NAME
:
Simranjit Rai
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/30/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/30/2023
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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