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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202033
Report Date: 08/23/2022
Date Signed: 08/23/2022 10:19:09 AM

Document Has Been Signed on 08/23/2022 10:19 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: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: 0DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nilda BautistaTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Lead DSP, Nila Bautista. Administrator, Maria Cristobal was contacted but was unable to meet LPA at the facility.

No clients observed on-site during visit and was stated to be attending day program. LPA toured the facility to include the dining room, living room, bedrooms, bathrooms, kitchen, garage, and backyard. All fire exit routes were free and clear of obstruction. Sharp objects and toxins were observed secured.

Facility has a designated entry point for COVID symptoms screening and temperature check for all staff and visitors. Hand sanitizer made available at entry and throughout the facility. Bathrooms supplies with paper supplies, hygiene products, and hand washing sign. Facility staff clean and disinfect multiple times daily and as needed. LPA observed sufficient Personal Protective Equipment (PPE) supplies. The following signs observed to include the visitation policy, symptoms of COVID, stop the spread of germs, and social distancing. Staff are not N95 fit-tested. LPA reviewed the facility's procedures to isolation, testing, visitation, and infection control training.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Lead DSP, Nila Bautista and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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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