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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202006
Report Date: 12/07/2022
Date Signed: 12/07/2022 11:42:15 AM

Document Has Been Signed on 12/07/2022 11:42 AM - 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 - WESTMONT HOMEFACILITY NUMBER:
435202006
ADMINISTRATOR:GRACE MENORFACILITY TYPE:
734
ADDRESS:1750 WESTMONT AVE.TELEPHONE:
(408) 364-1499
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 5CENSUS: 4DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Chellane LauronTIME COMPLETED:
11:43 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 01/31/2021. LPA met with facility staff member Chellane Lauron (S1). Administrator Grace Menor (Admin) was sick and unable to attend the inspection. LPA confirmed with Admin that the inspection could be carried out and the report could be signed by S1.

LPA toured the facility, including living room, kitchen, dining room, 5 bedrooms, 1 office, 3 bathrooms, garage, laundry room and back yard. All staff members observed to be wearing masks. S1 confirmed that all staff and residents have been vaccinated.

Facility infectious control plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in November of 2022.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. All restrooms stocked with paper towels. Water temperature observed to be 112 *F. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. This report was reviewed with facility staff member Chellane Lauron.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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