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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201958
Report Date: 11/28/2023
Date Signed: 11/28/2023 12:46:38 PM

Document Has Been Signed on 11/28/2023 12:46 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:CATHELEEN RCH-I & II DBA:CATHELEEN RCH IIFACILITY NUMBER:
435201958
ADMINISTRATOR:PHILIP NUNGAFACILITY TYPE:
735
ADDRESS:2513 SHILSHONE CIRCLETELEPHONE:
(408) 294-1296
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Licensee Guadelia FerrerTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Licensee(LN) Guadelia Ferrer . During visit, LPA observed 0 residents and 1 staff.

LPA toured the facility inside out with LN which included; the Living room, kitchen, dining room, family 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 closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 109 degrees F in both resident bathrooms.

Fire extinguisher was serviced in January 4, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by LN, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on August 14, 2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA review 3 resident P&I records. LPA conducted interviews with 1 staff (S1). Residents were attending day program during LPA's visit, and could not be interviewed.

LPA discussed with Licensee the change of ADM. LPA requested the following documents; Board resolution letter from the board appointing the new administrator, updated LIC200, Updated LIC500, ensuring the new ADM is associated to the facility, a copy of new ADM application, ARF Administrators certificate, & Resume.
No deficiencies cited during today's visit. This report was reviewed with LN Guadelia Ferer and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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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