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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202417
Report Date: 10/27/2022
Date Signed: 10/27/2022 04:36:27 PM

Document Has Been Signed on 10/27/2022 04:36 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Jose DucusinTIME COMPLETED:
02:39 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with staff Jose Ducusin (S1). Upon arrival, S1 took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside and out with S1. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed. Kitchen, dinning room and two restrooms were inspected. One trash can was observed without covers. S1 stated the facility will replace with thrash can with cover in 3 days. Some paper towels were observed without holders. S1 stated the facility will put all the paper towels with holders in 3 days. Posters of washing hands were observed, but there were no posters of washing hands for 20 seconds by the sinks in kitchen. S1 stated the facility will put the posters of washing hands for 20 seconds in the kitchen in 3 days. Four resident bedrooms, and laundry room were inspected. One staff live-in room was observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 70 degree F, and hot water temperature was at 114 degree F in facility. 2 residents were observed in facility.

Fire extinguisher was serviced on 5/16/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

S1 stated all the residents and staff are fully vaccinated and done with boosters. S1 stated the facility already submitted the Infection Control Plan to CCL office. No citation were noted today. Exit interview was conducted with S1. This report was provided to S1
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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