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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202614
Report Date: 12/16/2023
Date Signed: 12/16/2023 01:21:41 PM

Document Has Been Signed on 12/16/2023 01:21 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:THORNMILL HOUSEFACILITY NUMBER:
435202614
ADMINISTRATOR:ANA LUISA MEJIAFACILITY TYPE:
735
ADDRESS:1269 THORNMILL WAYTELEPHONE:
(808) 634-4085
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
12/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Ana Luisa MejiaTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Ana Luisa Mejia . During visit, LPA observed 4 residents and 3 staff.

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways. LPA observed the garage was being used as a laundry room/ storage area.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 118 degrees F in both resident bathrooms.

Fire extinguisher was serviced in January 24, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 5, 2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records. LPA conducted interviews with 2 staff (S1 to S3) and 2 residents (R1-R2).

No deficiencies cited during today's visit. This report was reviewed with Administrator Ana Luisa Mejia and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2023
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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