<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202267
Report Date: 12/28/2022
Date Signed: 12/28/2022 11:08:23 AM

Document Has Been Signed on 12/28/2022 11:08 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: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: 1DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Stephanie Valera TIME COMPLETED:
11:10 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) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. Administrator (ADM), Stephanie Valera was unable to meet LPA at the facility and instead conducted a Facetime visit. LPA also met with Direct Support Professional (DSP), Cora Borre.

During visit, LPA and DSP toured the facility to include the living rooms, kitchen, bedrooms, bathroom, garage, and backyard. All fire exit routes were free and clear of obstruction. Staff present was fingerprint cleared and associated to the facility. Staff observed wearing a face covering.

Facility has a central entry point for symptoms screening, temperature check, and sign-in for all visitors, staff, and residents. Hand sanitizer and Personal Protective Equipment (PPE) supplies made available at entry. Bathroom supplied with hygiene products, paper supplies, and hand washing sign. Trash bin with lid observed throughout the facility. Facility staff clean and disinfect multiple times daily and as needed. Facility staff are trained on infection control and are N95 fit-tested. The facility has procedures to isolation for COVID-19 and visitation. The following posters observed to include hand washing, cough etiquette, donning and doffing, symptoms of COVID, feeling ill, and social distancing.

The following documents were requested to include: Change of Administrator, LIC9182, DL/ID, LIC508 and Administrator Certificate.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with DSP, Cora Borre and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1