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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202592
Report Date: 10/24/2025
Date Signed: 10/24/2025 12:28:30 PM

Document Has Been Signed on 10/24/2025 12:28 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: 4DATE:
10/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Bonnie L Jiracek-CoddTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 10/24/2025 Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced required 1 year inspection, met with administrator (ADM) Bonnie Jiracek-Codd and stated the purpose of the visit.

The facility serves adult 18-59 years old who are ambulatory and developmentally challenged. The facility has a current census of 4 resident. 2 Out of 4 resident and 6 staff are present at the facility at the time of the visit . 2 Out of 4 resident are out attending day program. The 2 residents present at the facility are both resting.

LPA toured the facility with ADM inside and outside. LPA inspected 4 resident bedroom, 2 bathroom, living room, kitchen, office, garage laundry and backyard area of the facility. LPA observed that the backyard, walkways, hallways and exits are free of debris and from any obstruction.

Bathroom were equipped with grab bars and nonskid mats. Each resident has their personal hygiene supply caddy, labeled and kept in a secure place. The toxins, cleaning and laundry supplies are kept in a locked cabinet. Linens and extra towels are kept in the laundry area. The facility has working washer and dryer. LPA observed that water closet lids are secured for safety, bathroom mirrors are shatter proof. Medications AR kept in a locked cabinet inside the office. Sharp objects were locked and inaccessible to residents. Facility is equipped with a well water reservoir.

see LIC 809C
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 10/24/2025
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Facility temperature is maintained at 70 degrees Fahrenheit. LPA measured the water temperature with a digital thermometer. The water temperature measured at 111 degree F. Facility keeps record of the water temperature and measured at least once a week to ensure that water temperature is between 105 to 120 degree F. LPA observed freezer and refrigerators combination and one chest freezer. The temperature of the refrigerator is at 32 degree F and freezer temperature measured at 0 degree F.

LPA observed 2 days of perishable food and 7 days of non-perishable food & bottled drinking water. The facility is able to sustain resident and staff in the event of an emergency as observed based on the food supply stored at the facility pantry.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last inspected on 08/08/2025. LPA verified that the fire drill training was conducted 10/7/2025, earthquake drill training 10/17/2025, disaster training 9/24/25. The facility has first-aid kit that are available, flashlight, and recently acquired a generator in case of power outages.

LPA reviewed 4 resident records and verified that records were complete and updated including but not limited to the Centrally Stored Medication and Destruction Record (CSMDR), personal and incidental (P&I) allowance, medical assessment (LIC 602), appraisal needs and services plan (ANS), and individual program plan (IPP).

LPA verified that facility staff have fingerprint and criminal record clearance or criminal record exemption to work at the facility. Facility staff have current first aid certificates, updated training as required for their position and job duties as Direct Support Professional (DSP) and have taken 40 hours online courses for RBT to complete requirement of the San Andreas Regional Center (SARC) for one to one staffing.

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.

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end of report
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC809 (FAS) - (06/04)
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