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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202115
Report Date: 09/30/2024
Date Signed: 09/30/2024 10:24:34 AM

Document Has Been Signed on 09/30/2024 10:24 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:FLINTCREST HOUSE IIFACILITY NUMBER:
435202115
ADMINISTRATOR/
DIRECTOR:		NILO AMBAGANFACILITY TYPE:
735
ADDRESS:3094 STEVENS LANETELEPHONE:
(408) 528-7734
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Nilo Ambagan TIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analyst (LPAs) Simi Rai and Marcela Yanez conducted an unannounced annual inspection visit. LPAs met with Administrator (AD) Nilo Ambagan and stated the purpose of the visit. LPAs observed 2 Staff and 0 residents at the facility as 6 residents were attending the day program.

LPAs toured the facility inside and out with AD which included the Living room, kitchen, dining room, 2 restrooms and 4 residents bedrooms. LPAs measured the water temperature with thermometer in Kitchen sink measured at 112.4 degrees F and bathroom #1 and #2 sink measured with thermometer range from
112.5-113.0 degrees F.

LPAs observed a shed that was used for storage and locked and inaccessible to residents in care and not used as habitual space. LPAs observed chemicals and knives were locked and inaccessible to residents in care.

Two staff rooms and Office of the facility was also inspected. The front yard and backyard were inspected and exits were clear of obstruction and debris.

Fire extinguisher was serviced in 03/16/2024. The facility was equipped with working smoke and carbon monoxide detectors. LPAs observed flashlight and complete first aid kit. Facility fire/earthquake drill was conducted on 08/15/2024 and 09/23/2024.

LPAs reviewed facility records for 2 staff and 2 residents. LPA reviewed 2 resident medications and centrally stored medication records.

No deficiencies cited during today's visit per California Code of Regulation Title 22. This report was reviewed with Administrator (AD) Nilo Ambagan and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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