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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202417
Report Date: 11/21/2023
Date Signed: 11/21/2023 10:04:28 AM

Document Has Been Signed on 11/21/2023 10:04 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: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:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Staff member Quintin ZacariasTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff member (S1) Quintin Zacarias. Staff member called administrator (ADM) Remedios, ADM stated she could not come to the facility due to being sick. ADM stated staff can sign on her behalf. During visit, LPA observed 1 residents and 1 staff.

LPA toured the facility inside out with S1 which included; the kitchen, dining room, 2 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 118 degrees F in both resident bathrooms.

Fire extinguisher was serviced in September 28, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on September 28, 2023.

LPA reviewed facility records for 2 staff and 2 residents. LPA reviewed 2 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff (S1) and 1 resident (R1). The other resident had already left for day program and could not be interviewed.

No deficiencies cited during today's visit. This report was reviewed with S1 and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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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