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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202267
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:15:47 PM

Document Has Been Signed on 05/04/2023 12:15 PM - 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:STEPHANIE VALERAFACILITY TYPE:
735
ADDRESS:7315 WREN AVENUETELEPHONE:
(408) 847-6441
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 2DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Stephanie ValeraTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Administrator, Stephanie Valera.

The purpose of the visit was to follow-up on an incident report and SOC341 received from resident (R1)’s day program alleging physical and verbal abuse from residential facility staff members (S1 – S2).

During visit, LPA interviewed two residents and two staff members. Based on interviews, residents and staff have not observed physical and verbal abuse from S1 - S2 or other staff members. On 04/25/2023, R1 had a decrease in medications. The Administrator is in communication with R1's physicians, family member, and service coordinator regarding the goal of giving R1 a better quality of life. The review of records show R1 has behaviors of outburst and frustration. The facility plan is to practice techniques and appropriate ways to express R1's emotions. After the alleged incident, the Administrator removed S1 - S2 from working in the facility, conducted an internal investigation by interviewing staff members and residents with no findings or indication of abuse, and created a new verbal plan in communicating with R1 regarding daily activities.

The following documents were reviewed and obtained to include: R1's physician's report, Individual Program Plan (IPP), appraisal needs and services plan, progress nores, and medication administrator record (MAR).

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Stephanie Valera and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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