<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202592
Report Date: 08/29/2024
Date Signed: 08/29/2024 10:57:56 AM

Document Has Been Signed on 08/29/2024 10:57 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:FOOTHILL ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
435202592
ADMINISTRATOR/
DIRECTOR:		BONNIE L JIRACEK-CODDFACILITY TYPE:
735
ADDRESS:13655 FOOTHILL AVETELEPHONE:
(669) 231-3861
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 4CENSUS: 3DATE:
08/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Bonnie Jiracek-CoddTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/292024 at 9:15 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived at the facility and conducted an unannounced case management for the incident received by the department on 7/31/2024 and 8/22/2024. LPA met with the facility administrator (ADM) Bonnie Jiracek-Codd. LPA stated the purpose of the visit.

The facility serves 18-59 years old who are ambulatory and are developmentally disabled. The facility has a capacity of 4 and current census is 3, with pending intake of 1.

LPA withe toured the facility inside and outside and met with 1 of 3 resident.

On 7/31/2024, the facility experienced a power outage for 8 hours. ADM stated it was extremely hot that day. ADM stated that the facility does not have a generator. ADM stated they were about to place the residents in a hotel when the power came back up. ADM stated they experience power outages at least once every month or once every 3 or 4 months. Due to the location the gas generator is not encourage the city of San Martin.

LPA inquired about SOC341 (report of suspected elder abuse form) received by the department and ADM stated there is no abuse happening, physical or sexual at the facility and they are not a day program but a residential care facility. Upon further research there was a confusion regarding the facility where the incident of abuse happened.

No deficiency were cited during today's visit base on California Code of Regulation (CCR) Title 22. An exit interview was conducted with Administrator Bonnie Jiracek-Codd and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1