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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202633
Report Date: 09/16/2023
Date Signed: 09/16/2023 02:40:02 PM

Document Has Been Signed on 09/16/2023 02:40 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:EDGEVIEW MANORFACILITY NUMBER:
435202633
ADMINISTRATOR:CAPALLA, SHARI LYNNFACILITY TYPE:
735
ADDRESS:1989 EDGEVIEW DRIVETELEPHONE:
(408) 677-3563
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: 5DATE:
09/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Shari CapallaTIME COMPLETED:
02:45 PM
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On 09/16/2023, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced required Annual inspection visit at the facility. LPA met with Administrator (ADM) Shari Capalla. .

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dinning area, two restrooms and 4 residents bedrooms. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication locked cabinet , knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. LPA measured the facility hot water temperature at 108 degrees F in both resident bathrooms.

Fire extinguisher was serviced in June 14, 2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by FM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on May 22, 2023.

LPA reviewed facility records for 2 staff and 2 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff (S1 to S2) and 2 residents (R1-R2).

No deficiencies cited during today's visit. This report was reviewed with Facility Manager Shari Capalla and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2023
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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