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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202342
Report Date: 03/21/2024
Date Signed: 03/21/2024 02:14:36 PM

Document Has Been Signed on 03/21/2024 02:14 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:LA CROSSE HOME INCFACILITY NUMBER:
435202342
ADMINISTRATOR:PERLA CAYABYABFACILITY TYPE:
735
ADDRESS:256 LA CROSSE DRIVETELEPHONE:
(408) 499-3708
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 6CENSUS: 5DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Perla CayabyabTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Perla Cayabyab. LPA Rai observed 2 staff and 0 residents at the facility since 5 residents were attending day program.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed a locked shed which was used for storage and not habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the resident bedrooms. 4 out of 4 resident bedrooms had available bedding, drawers, and functioning lights.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.8 - 107.6 degrees F. The water temperature in the kitchen sink was 105.8 degrees F. Fire extinguisher was observed and inspected on 1/16/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 3/9/2024.

LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records. LPA Rai reviewed LIC 405 Record of Client's/Resident's Safeguard Cash Resources and 2 out of 2 resident records observed were accurate.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator (ADM) Perla Cayabyab and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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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