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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202485
Report Date: 12/21/2024
Date Signed: 12/21/2024 09:17:21 AM

Document Has Been Signed on 12/21/2024 09:17 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:COUNTRY STYLE LIVINGFACILITY NUMBER:
435202485
ADMINISTRATOR/
DIRECTOR:
NORA DENNISFACILITY TYPE:
740
ADDRESS:2231 SUTTER AVENUETELEPHONE:
(408) 260-2844
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
12/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Administrator Nora DennisTIME VISIT/
INSPECTION COMPLETED:
09:20 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Nora Dennis. During the visit, LPA observed 2 residents and 1 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 4 residents bedrooms. LPA toured the facility garage, which is being used as a laundry area and a car storage area. The staff area of the facility was also inspected. The front yard and backyard were inspected. LPA observed a shed in the backyard, being used as a storage space. 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 storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 109 degrees F in hallway bathroom.

Fire extinguisher was serviced in March 4, 2024. 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 September 29, 2024.

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

LPA provided ADM with CDSS Flyer, "Important updates to Dementia Care and Miscellaneous Changes, effective January 1, 2025."
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Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112
DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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: COUNTRY STYLE LIVING
FACILITY NUMBER: 435202485
VISIT DATE: 12/21/2024
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LPA requested a copy of the following documents;
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. Qualifications of Administrator (Certificate)
6. Please review your facility program for updates (incorporating new laws and/or regulations)
7. LIC309, Administrative Organization


No deficiencies cited during today's visit. This report was reviewed with Administrator Nora Dennis and a copy of the signed report was provided.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC809 (FAS) - (06/04)
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