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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202005
Report Date: 10/24/2024
Date Signed: 10/29/2024 03:25:28 PM

Document Has Been Signed on 10/29/2024 03:25 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:CA NATIONAL MENTOR - CALERO HOMEFACILITY NUMBER:
435202005
ADMINISTRATOR/
DIRECTOR:		BEVERLY OLIVEROSFACILITY TYPE:
734
ADDRESS:826 CALERO AVE.TELEPHONE:
(408) 224-4522
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 5CENSUS: 4DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Beverly OliverosTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Required 1 Year visit and met with Administrator, Beverly Oliveros and stated the purpose of the visit.

The facility serves 5 adults with special health care needs who are developmentally disabled 18 years and over and all five may be bedridden.

LPA inspected the kitchen, dining, activity room, 5 resident room, garage, bathroom and exterior perimeter.

LPA observed food supply of at least 2 days of perishable food and 7 days of nonperishable food, including emergency supply formulas for 7 days. Sharps and medications were locked in secured areas. Cleaning and laundry supplies are in a separate storage and locked under the sink. The water temperature in the kitchen measured at 112.8

The facility bathroom had available soap, paper towels, and trash cans with lids. The shower is equipped to serve adults who are non-ambulatory, non-skid mats and grab bars. The water temperature in the bathroom measured at 118.9 degree F.

Facility smoke detectors and carbon monoxide detectors were in working condition. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. LPA toured the inside and outside of the facility. The facility is equipped with generator. The exterior walkways, pathways and exits were free from obstruction.

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see LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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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: CA NATIONAL MENTOR - CALERO HOME
FACILITY NUMBER: 435202005
VISIT DATE: 10/24/2024
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LPA Partoza reviewed facility records for 4 staff and 4 residents. The resident medications and central stored medication records were current and up to date, the facility training record for fire and disaster training was administered on 10/14/2024. Fire extinguisher was last inspected 9/20/2024.

No deficiencies were cited during today's visit. An exit interview was conducted with administrator Beverly Oliveros and a copy of the report was provided.

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end of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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