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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202429
Report Date: 03/23/2024
Date Signed: 03/23/2024 09:32:15 AM

Document Has Been Signed on 03/23/2024 09:32 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:A. & T. CARE HOME #3FACILITY NUMBER:
435202429
ADMINISTRATOR:TRAM N. TRUONGFACILITY TYPE:
735
ADDRESS:2495 DASHWOOD AVENUETELEPHONE:
(408) 622-4240
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
03/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Tram TruongTIME COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Tram Truong. During the visit, LPA observed 4 residents and 2 staff.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. While touring the facility, LPA observed the window screen in the kitchen was damaged. LPA observed the window screen, in the resident bedroom with the master bath, had a damaged window screen as well. ADM stated she was planning on fixing the screens this weekend.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 72 degrees F, and hot water temperature was measured at 112 degrees F in both resident bathrooms.

Fire extinguisher was serviced in August 11, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on March 12, 2024.

LPA reviewed facility records for 2 staff and 2 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 2 residents.

No deficiencies cited during today's visit. A technical violation was given. This report was reviewed with Administrator Tram Truong and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2024
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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