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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202517
Report Date: 09/11/2024
Date Signed: 09/11/2024 01:32:02 PM

Document Has Been Signed on 09/11/2024 01:32 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:NATIONAL PSYCHIATRIC CARE AND REHABILITATION SERVFACILITY NUMBER:
435202517
ADMINISTRATOR/
DIRECTOR:		ANTHONY WILLIAMSFACILITY TYPE:
772
ADDRESS:650 SOUTH 5TH STREETTELEPHONE:
(408) 568-1174
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 15CENSUS: 7DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Monique RankinTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analysts (LPAs) David Marrufo and LPA Santino Fortes conducted an unannounced annual inspection visit, and met with Program Manager (PM) Monique Rankin . PM informed LPA that the facility has 19 staff and 7 clients.

LPAs toured the facility inside out with which included: kitchen, office areas, 8 resident rooms and 4 restrooms. LPAs observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. The staff area of the facility was also inspected. The front yard and backyard of the facility was also inspected. There was no obstruction to block the outdoor exits.

LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Room temperature was at 72 degree F, and hot water temperature was measured 3 out of 3 hallway resident restrooms measured at 120, 119.8, and 115.3 degrees F.

The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested. One smoke detector emitted a sound indicating it had a low battery. Staff brought over a new smoke detector during visit, but were waiting on a maintenance staff to arrive in order to mount the new smoke detector. Fire extinguishers were last serviced on June 6, 2024. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed. The facility's last drill was on 08/01/2024.

LPA reviewed facility records for 5 staff and 5 clients, which were all found to be complete during review. LPA reviewed 5 clients medications and centrally stored medication records and found the centrally stored medication records to be complete. No deficiencies were cited during today's visit as per California Code of Regulations Title 22. An Advisory Note was issued. See LIC9102 for more information. This report was reviewed with PM Monique Rankin and a copy of the signed report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Santino Fortes
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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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