<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201943
Report Date: 01/15/2025
Date Signed: 01/15/2025 03:58:34 PM

Document Has Been Signed on 01/15/2025 03:58 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
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/
DIRECTOR:		MARIA VALENTINA CRISTOBALFACILITY TYPE:
735
ADDRESS:2334 OAK FLAT ROADTELEPHONE:
(408) 923-2933
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: 3DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Maria Valentina CristobalTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Maria Valentina Cristobal, Administrator. LPA announced the purpose of the visit. LPA observed 3 staff and 1 resident and 2 of 3 resident at day program.

During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days, Refrigerator temperature was measured at 39 degrees F and freezer was measured at 0 degrees F, and room temperature was 71 degrees F.

LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. ADM tested the smoke detectors in the living room and found the smoke detector to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer between 112 to 119 degrees F.

LPA toured the outside area and found the exits to be clear of obstructions. LPA observed 2 locked sheds in backyard and are being used as storage and not being used as living quarters. LPA observed fire extinguisher was last serviced on 04/25/24. Facility has a pull fire alarm and was last serviced on 04/08/24. LPA reviewed Fire and Earthquake log last drill for earthquake was conducted on 11/05/24 and fire drill on 11/03/24.

Page 1 of 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 01/15/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
page 2 of 2

LPA reviewed 3 resident record, CSMDR and P&I was reviewed with ADM and found to be complete.

No deficiency were cited as per California Code of Regulations Title 22. This report was reviewed with Maria Valentina Cristobal and a copy of this report was provided.

End of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2