435202208-12-6-2025-26-AS-MPAA-DP4PH4-20251206101920

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202208
Report Date: 12/06/2025
Date Signed: 12/06/2025 10:19:54 AM

Document Has Been Signed on 12/06/2025 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:	MILES RESIDENTIAL CARE HOME		FACILITY NUMBER:	435202208
ADMINISTRATOR/ DIRECTOR:	NAOMI APOSTOL-MILES		FACILITY TYPE:	735
ADDRESS:	5764 CHESBRO AVE.		TELEPHONE:	(408) 921-8387
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 6		CENSUS: 4	DATE:	12/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:25 AM
MET WITH:	Naomi Apostol-Miles		TIME VISIT/ INSPECTION COMPLETED:	10:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Naomi Apostol-Miles and stated the purpose of the visit. The facility serves 18 to 59 years old who are developmentally challenged and all may be non-ambulatory. LPA inspected the facility inside and outside and observed the exits were clear of obstruction. Inspected 3 resident rooms, staff room, office area, 2 bathrooms, 2 living area, kitchen and garage. LPA Partoza observed food supply of 2 days of perishable foods and 7 days of non-perishable foods. LPA Partoza observed locked cabinets for chemicals, medications and sharp objects and are not easily accessible to residents in care. LPA observed the washer and dryer in the garage area was in good working, chemicals are separated from the food pantry. LPA observed 3 out of 3 resident room were sanitary and organized and have sufficient storage for residents' personal belongings. 2 Out 2 bathroom used by residents have grab bars and anti-skid floor mats. The facility has a dining area and living area that are free from debris or obstruction. LPA Partoza measured the hot water temperature for 2 out of 2 bathrooms and kitchen. The water temperature was measured with a digital thermometer at 105 degrees F. The facility room temperature is at 71 degree F. LPA observed refrigerator, freezer combination in the kitchen, 1 upright freezer in the garage . The refrigerator temperature measured at 38 degree F and freezer is at 0 degree F. page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: MILES RESIDENTIAL CARE HOME	FACILITY NUMBER: 435202208
	VISIT DATE: 12/06/2025

NARRATIVE

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The facility has carbon monoxide detectors and smoke alarms that are in good working condition. The facility is equipped with a fire extinguisher and inspected on 04/03/2025. Emergency preparedness training, was last conducted on 12/01/2025, Fire and earthquake drills were done on 01/5/25, 2/9/25, 3/18/25, 6/7/25, 7/4/25, 9/7/25, 10/10/25.

LPA reviewed 4 Out of 4 resident files were observed that residents files were complete and updated including but not limited to Centrally Stored Medication and Destruction Record (CSMDR). Personal and Incidental (P&I) allowance, appraisal needs and services plan, medical assessment, personal rights and consent forms, and personal and incidental allowance.

LPA reviewed 3 staff record, and observed that the staff records were complete and updated including but not limited, to staff training and 1st Aid/CPR certificates, criminal background clearance, health screening, mandated reporter (SOC 341A).

No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Administrator Naomi Apostol-Miles. A copy of the report was provided.

End of Report
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2025

LIC809 (FAS) - (06/04)

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