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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202492
Report Date: 06/06/2024
Date Signed: 06/06/2024 04:27:43 PM

Document Has Been Signed on 06/06/2024 04:27 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:DYSICO CARE HOME, ARFFACILITY NUMBER:
435202492
ADMINISTRATOR/
DIRECTOR:
MARIA BONUANFACILITY TYPE:
735
ADDRESS:787 E. SAN CARLOS STREETTELEPHONE:
(408) 286-5364
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 6CENSUS: 6DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Angelica BonuarTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Angelica Bonuar.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo toured the kitchen area and found there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed locked storage areas for medications, sharps, and cleaning supplies. LPA observed the first aid kit to be complete.

LPA toured three out of three resident bedrooms and observed each bedroom to have working lights as well as available bedding and clothing storage areas. LPA Marrufo tested the smoke detectors in each bedroom and one smoke detector had a faint sound when tested. The other smoke detectors had a more audible sound when tested. The facility hallway had three smoke detectors and one of them had a faint sound when tested and the other two had audible sounds when tested. Each smoke detector also functioned as a carbon monoxide detector. LPA Marrufo toured two out of two facility bathrooms. Each bathroom had functioning lights. There were available paper towels and soap for residents. The water temperatures in the bathrooms were 119 F and 117 F.

The Personal and Incidental Money Log was reviewed and found to be balanced. The Centrally Stored Medication Log was reviewed and found to be complete. The resident records and staff records were reviewed and found to be complete. The Emergency Disaster Drill Log was reviewed and the last recorded drill was on 03/12/2024.

No deficiencies were cited as per California Code of Regulations Title 22. An Advisory Note was issued. See LIC9102 for more information. This report was reviewed with Angelica Bonuar and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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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