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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201943
Report Date: 01/31/2023
Date Signed: 01/31/2023 05:00:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/31/2023 05:00 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:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Nilda Bautista, assistant ADMTIME COMPLETED:
03:59 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Assistant Administrator Nilda Bautista (AADM) . Upon arrival, AADM took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside and out with AADM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Living room, family room, kitchen, dinning room and two restrooms were inspected. One trash cans was observed without cover. AADM replaced with a trash can with cover before LPA left the facility. Paper towels were observed with holders. Cloth towels were observed in kitchen and restrooms. Three single resident bedrooms, and laundry room were inspected. One staff live-in room are in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 73 degree F, and hot water temperature was at 107 degree F in facility. Three residents and 4 staff were observed in facility.

Fire extinguisher was serviced on 05/02/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by AADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

AADM stated all the residents and staff are fully vaccinated and done with booster. AADM stated the facility already submitted the Infection Control Plan to CCL office.

No citation were noted today. Exit interview was conducted with AADM. This report was provided to AADM for signature. A copy of the report was provided to AADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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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