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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202553
Report Date: 01/23/2025
Date Signed: 01/23/2025 04:39:35 PM

Document Has Been Signed on 01/23/2025 04:39 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:CAPITOL CARE HOMEFACILITY NUMBER:
435202553
ADMINISTRATOR/
DIRECTOR:
DEGUZMAN, JOHANNFACILITY TYPE:
735
ADDRESS:849 S CAPITOL AVENUETELEPHONE:
(408) 644-9278
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Johann DeguzmanTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with Administrator (ADM) Johann Deguzman (ADM).

LPA observed 2 staff (S1, S2) and 1 resident (R1) in the facility. LPA reviewed 3 resident files (R1 - R3) and 3 staff files (S1 - S3).

LPA toured the facility inside out with ADM. License, personal rights posters, and Administrator Certificate were observed in the facility. Living room, dining room, garage and kitchen were inspected. 1 staff live-in room was observed in the facility. 3 resident bedrooms, 2 bathrooms were inspected. A half bed rail was observed on a bed of resident room for resident R1, ADM provided document to support the needs of R1.

Two days perishable foods and seven day non perishable foods were observed sufficient. Room temperature was observed at 71 degree F, hot water temperature was observed at 105 degree F. Medication cabinet, knife closet were observed locked. Dish cleaning soap solution was observed on the top of kitchen sink, ADM locked the dish cleaning soap solution immediately. Fire extinguisher was serviced on 10/13/2024. The facility was equipped with fire alarm system and carbon monoxide detectors. Fire alarm and carbon monoxide detectors were tested, and were functional. First aid box, and flash lights were observed in the facility. No night light was observed in the hallway. ADM put a night light in the hallway immediately. The last time facility conducted the emergency drill was on 12/18/2024.

Front yard and backyard were inspected. One storage room was observed at the backyard. There was no obstruction to block the walkways.
Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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