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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202552
Report Date: 06/14/2024
Date Signed: 06/14/2024 11:05:46 AM

Document Has Been Signed on 06/14/2024 11:05 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:CATHELEEN RES CARE HOME-IIIFACILITY NUMBER:
435202552
ADMINISTRATOR/
DIRECTOR:		SANDOVAL, RUBENITAFACILITY TYPE:
735
ADDRESS:1551 PRINCETON DRIVETELEPHONE:
(408) 267-2070
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 5DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Admnistrator, Rubenita SandovalTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Rubenita Sandoval. LPA Rai observed 2 staff (S1 & S2) and 1 resident at the facility. During the visit, 4 residents were attending day program. This facility is a level 4h and 5 out of 5 residents are Developmentally Disabled overseen by the San Andreas Regional Center.

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 observed 2 storage sheds locked and not used as habitual space. 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.

LPA Rai toured the resident bedrooms. 3 Out of 3 resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai observed 1 staff room which is used by 3 staff (S1, S2 and ADM) who are Criminally Record Cleared and associated to the facility.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.8 degrees F - 113.3 degrees F. The water temperature in the kitchen sink was 113.0 degrees F. Fire extinguisher was observed and inspected on 01/11/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 01/3/2024 and 5/16/2024.

LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai reviewed resident medications and central stored medication records. LPA Rai reviewed resident's LIC 405 Record of Resident's Safeguarded Cash Resources. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator (ADM) Rubenita Sandoval and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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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