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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202583
Report Date: 10/25/2024
Date Signed: 10/25/2024 04:44:44 PM


Document Has Been Signed on 10/25/2024 04:44 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:JESSIE COURT CARE HOMEFACILITY NUMBER:
435202583
ADMINISTRATOR:VU, KRISTINE ABLAOFACILITY TYPE:
740
ADDRESS:2934 JESSIE COURTTELEPHONE:
(408) 628-4702
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 4DATE:
10/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kristine VuTIME COMPLETED:
04:36 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Kristine Vu.

LPA checked 2 resident files and 2 staff files.

LPA toured the facility with ADM. License, Administrator Certificate and Personal right posters were observed in the facility. There are 2 staff live-in rooms, 5 resident rooms, and 3 restrooms in the facility. Grabbing bars and Non skid pads were observed in the bathrooms. 3 staff and 4 residents were observed in the facility. LPA toured the kitchen, dining room, family room, laundry room and living room. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The room temperature was 72 degree F, and the hot water temperature was 106 degree F. The temperature of the refrigerator was measured at 38 degree F, and the temperature of freezer was measured at 0 degree F. Medication cabinet was observed locked. Knives cabinet was observed locked. Cleaning chemical products cabinet under the sink were observed unlocked. ADM locked it immediately. Fire extinguisher was serviced on 05/08/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. First aid box, flash light for emergency, audio door alarm for the main entrance and night light were observed in the facility.

LPA toured backyard with ADM. No obstacles were observed blocked the walkway in the backyard. Two storage rooms were observed at the backyard. A empty swimming pool was observed locked at the back yard. The facility had emergency and fire drill on 10/01/2024.

No Deficiencies were noted today. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024
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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