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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201943
Report Date: 01/27/2024
Date Signed: 01/27/2024 06:14:14 PM

Document Has Been Signed on 01/27/2024 06:14 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: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:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Staff member Joselito DimeroTIME COMPLETED:
06:20 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff member Joselito Dimero (S1). S1 called Administrator (ADM) Maria Valentiana Cristobal and informed her of the purpose of the visit. During visit, LPA observed 2 residents and 3 staff.

LPA toured the facility inside out with S1 which included; the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 118 degrees F in both resident bathrooms.

Fire extinguisher was serviced in May 19, 2023. The facility was equipped with smoke and carbon monoxide detectors. ADM stated Smoke detectors was tested by Cintas on November 14, 2023 for their annual fire safety inspection. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on November 11, 2023.

LPA reviewed facility records for 2 staff and 2 residents. LPA reviewed 2 resident medications and centrally stored medication records. LPA reviewed 2 P&I records. LPA conducted interviews with 1 staff (S1) and 2 residents (R1-R2).

No deficiencies cited during today's visit. This report was reviewed with Staff member Joselito Dimero and ADM Maria Valentiana Cristobal. ADM stated S1 could sign on her behalf and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024
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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