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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202592
Report Date: 08/29/2024
Date Signed: 08/29/2024 12:33:22 PM

Document Has Been Signed on 08/29/2024 12:33 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: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:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Bonnie L Jiracek-CoddTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 8/29/2024, Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced required 1 year inspection and met with administrator (ADM) Bonnie Jiracek-Codd.

The facility serves adult 18-59 years old who are ambulatory and are developmentally disabled. The facility has a current census of 3 resident and 1 pending intake. LPA observed 2 of 3 residents and 3 staff. 1 of 3 is out attending day program at the CIT (Community Integrated Training also known as the Summit Day Program) located in San Jose. 1 of 3 was in the room resting and 1 of 3 left to attend a dance class.

At 10:30 a.m. LPA toured the facility with ADM inside and outside, including 4 resident bedroom, 2 bathroom, living room, office and garage. Walkways, hallways and exits were observed free from debris and obstruction. The backyard observed to be free from debris and maintained.

Bathrooms are equipped with grab bars and nonskid mats. Facility is equipped with comfortable lighting. Hygiene items and toiletries are available to the clients. Centrally stored medications, toxins, and sharp objects were locked and inaccessible to the clients. LPA observed 2 days of perishable food and 7 days of none perishable food.

Facility temperature is maintained at 72 degrees Fahrenheit. Facility is equipped with a well water reservoir and keeps logs for the water temperature and measured at least once a week. Water temperature measured between 104 degree F to 107 degree F.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last inspected on 5/29/2024. Fire drill was conducted on 08/22/2024.
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 435202592
VISIT DATE: 08/29/2024
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LPA reviewed clients and staff records. Facility staff all have criminal record clearance or criminal record exemption to work at the facility and are associated to the facility. Facility staff all have current first aid certificates. Stored medications were compared with the centrally stored medication log and observed to be current and updated. Clients cash resources were reviewed and found to be current and updated.

No deficiencies cited during today's visit, based on California Code of Regulation (CCR) Title 22. An exit interview was conducted with Administrator Bonnie Jiracek-Codd and a copy of this report 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
LIC809 (FAS) - (06/04)
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