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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202417
Report Date: 04/28/2022
Date Signed: 04/29/2022 09:12:58 AM

Document Has Been Signed on 04/29/2022 09:12 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,
, CA
FACILITY NAME:BAYMILL CARE HOMEFACILITY NUMBER:
435202417
ADMINISTRATOR:ZACARIAS, REMEDIOSFACILITY TYPE:
735
ADDRESS:2822 BAYSMILL COURTTELEPHONE:
(408) 225-9672
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 2DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Jose DucusinTIME COMPLETED:
06:10 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Jose Ducusin Direct Service Provider.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked cabinet in the kitchen. Fresh fruit of apples, bananas and cuties available for residents.

Facility observed to have designated entry point for COVID 19 symptom screening. Hand sanitizer available to visitors and residents. Bathrooms observed to be supplied with hygiene products. Hand washing signs posted in the bathrooms and in the kitchen.

LPA observed supply of Personal Protective Equipment (PPE).

No citations were issued per the California Code of Regulations Title 22.

LPA reviewed report with Jose Ducusin Direct Service Provid1er and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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