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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202041
Report Date: 10/15/2024
Date Signed: 10/15/2024 12:32:55 PM

Document Has Been Signed on 10/15/2024 12:32 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:LSA - SALERNO HOMEFACILITY NUMBER:
435202041
ADMINISTRATOR/
DIRECTOR:		TANCINCO, ARMIEFACILITY TYPE:
734
ADDRESS:1173 SALERNO DRTELEPHONE:
(408) 429-8274
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 5CENSUS: 4DATE:
10/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:26 AM
MET WITH:Seble Tamirat, Designated AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Marcella Tarin and Mita Partoza conducted an unannounced case management to address Department of Developmental Services (DDS) initial inspection visit, where deficiencies were observed. LPAs met with Seble Tamirat, Designated Administrator (DA). DA stated that the facility has 2 staff and 4 clients.

LPAs toured the facility inside out with which included: kitchen, office area, 4 resident rooms and 2 restrooms, and staff room. The facility temperature was 72 degrees F. LPAs observed two days of perishable food and seven days of non-perishable food. LPAs observed the refrigerator temperature at 37 degrees F and the freezer temperature at 0 degrees F. LPAs observed the refrigerator is equipped with a 'Smart Inverter' which automatically sets the temperature at 37 degrees F and 0 degrees for the freezer, which helps keep food fresh and prevents bacterial growth. LPAs inspected the dry pantry and did not observed any liquid or perishable food supply that stated "keep refrigerated." LPAs checked facility records for staff training on food safety/services. The last food safety/services training was conducted on 09/24/2024.
LPAs inspected exterior perimeters and observed no obstruction on the walkways.

No deficiencies were cited during today's visit. A copy of this report was provided and an exit interview was conducted with Designated Administrator, Seble Tamirat.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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