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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202541
Report Date: 09/01/2023
Date Signed: 09/01/2023 11:23:40 AM

Document Has Been Signed on 09/01/2023 11:23 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:NORTH VALLEY HOMEFACILITY NUMBER:
435202541
ADMINISTRATOR:GOLTIAO, JANETTEFACILITY TYPE:
735
ADDRESS:3578 DINNY STREETTELEPHONE:
(408) 802-3119
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 6CENSUS: 6DATE:
09/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator, Janette GoltiaoTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator Janette Goltiao. LPA Rai observed 2 staff and 0 residents at the facility since residents were attending day program.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

The facility bathroom had available soap, paper towels, and trash cans with lids. The shower had grab bars and non-skid mats. The water temperature in the bathroom sinks ranged from 107.6F-108.1F. The water temperature in the kitchen sink was 107.9F. Fire extinguisher was observed and inspected on May 2023. Facility smoke detectors and carbon monoxide detectors were in working condition. 4 out of 4 resident bedrooms had available bedding, drawers, and functioning lights.

LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai reviewed resident medications and central stored medication records.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Janette Goltiao and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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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