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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202092
Report Date: 10/25/2023
Date Signed: 10/31/2023 08:41:57 AM

Document Has Been Signed on 10/31/2023 08:41 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:THELMA'S HOMEFACILITY NUMBER:
435202092
ADMINISTRATOR:THELMA B. RUIZFACILITY TYPE:
735
ADDRESS:1164 CAMANO CT.TELEPHONE:
(408) 292-6631
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: 6DATE:
10/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:House Manager Elenita GanoTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with House Manager(HM) Elenita Gano. HM called Administrator Thelma Ruiz, and ADM stated HM could sign on her behalf.

LPA toured the facility inside out with HM which included; the recreation room, kitchen, dining room, 4 resident bedrooms and 1 hallway bathroom. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication cabinet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 107 degrees F in facility bathroom.

Fire extinguisher was serviced in June 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by HM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 1, 2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident's P&I records. LPA conducted interviews with 1 staff (HM). Residents were not in the facility and were attending day program during LPA's visit.

No deficiencies cited during today's visit. This report was reviewed with HM Elenita Gano and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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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