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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202267
Report Date: 12/14/2021
Date Signed: 12/14/2021 11:00:45 AM

Document Has Been Signed on 12/14/2021 11:00 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:
12/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Maria VirayTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a Required 1-year annual inspection to focus on infection control. LPA met with Administrator, Mira Viray.

During visit, it was concluded that the facility's annual was conducted on 12/9/2021 by LPA David Marrufo.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Caregiver, Romeo Tambua, and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2021
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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