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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202267
Report Date: 12/09/2021
Date Signed: 12/09/2021 11:09:23 AM

Document Has Been Signed on 12/09/2021 11:09 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NATHAN'S RESIDENTIAL CARE HOME, INC.FACILITY NUMBER:
435202267
ADMINISTRATOR:MARIA ANTOINETTE G. VIRAYFACILITY TYPE:
735
ADDRESS:7315 WREN AVENUETELEPHONE:
(408) 847-6441
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Antoinette VirayTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Maria Antoinette Viray.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed there to be a visitor screening area at the facility entrance. LPA Marrufo observed a PPE supply of at least 30 days. There was a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo toured the hallways and observed COVID-19 related posters. 2 out of 2 resident bathrooms had hand washing signs and available soap and paper towels. The outdoor exits were found to be clear of obstructions.

No deficiencies were cited at this time as per California Code of Regulations Title 22.


This report was reviewed with Administrator Maria Antoinette Viray and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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