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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202033
Report Date: 09/15/2021
Date Signed: 09/30/2021 03:04:14 PM

Document Has Been Signed on 09/30/2021 03:04 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CCC ARF, INC. DBA NANTUCKET HOME #4FACILITY NUMBER:
435202033
ADMINISTRATOR:MARIA VALENTINA CRISTOBALFACILITY TYPE:
735
ADDRESS:2917 PENITENCIA CREEK RD.TELEPHONE:
(408) 259-6146
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 3CENSUS: 3DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Maria Valentina CristobalTIME COMPLETED:
12:40 PM
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Licensing Program Analyst, Steve Nguyen, conducted an unannounced annual inspection with Administrator Maria Valentina Cristobal.

LPA toured facility inside and out. LPA observed: Covid signs are present and in conspicuous vantage points, emergency contact for residents were up to date, facility screening protocols were in effect, hand sanitizing station were available throughout facility, medicine cabinet were observed to be locked, paper towers are in use, all rooms in facility are functional and physical distancing was observed to be in practice.

No citation was issued at this time.

LPA went over report findings with Administrator Maria Valentina Cristobal for review and a copy was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2021
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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