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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202645
Report Date: 12/21/2023
Date Signed: 12/21/2023 04:46:52 PM

Document Has Been Signed on 12/21/2023 04:46 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
Lookup Error,
, CA
FACILITY NAME:SLEEPY HOLLOW CARE HOMEFACILITY NUMBER:
435202645
ADMINISTRATOR:DEGUZMAN, JOHANNFACILITY TYPE:
735
ADDRESS:2491 SLEEPY HOLLOW LNTELEPHONE:
(408) 644-9278
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6CENSUS: 4DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Johann DeGuzmanTIME COMPLETED:
05:05 PM
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On 12/21/23, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA introduced self, stated purpose of visit, and allowed entrance by lead staff. Administrator, Johann DeGuzman contacted by telephone and arrived a short time later to conduct inspection.

Facility tour conducted with lead staff. Facility tour began inside facility. Facility observed to be clean, odor free, well lit, and a comfortable temperature. All common areas observed to have adequate seating for the residents in care. Resident bedrooms observed to have all required furnishings. Bathroom toured and observed to have grab bars, non-slip surface in bathtub and shower chair available. Water temperature measured at 120 degrees F during inspection visit. Kitchen toured, LPA observed all sharps to be locked and secured in kitchen drawer. Food observed to be properly stored, labeled, and dated in refrigerator. LPA observed a 2-day supply of perishable food but not a 7-day of non-perishable available for residents. Medications observed to be locked and secured. All medications observed to have original labels and to be administered as prescribed. All cleaning supplies observed to be locked and secured in cabinet in garage.

Facility is equipped with pull station, carbon monoxide observed to be operational during inspection. Fire extinguisher present with a service date of 11/9/23. Last fire drill and earthquake drill conducted on 11/29/2023 according to facility records.

Outside of facility toured, all exits open free of obstruction. Shed in backyard is locked and secured. No hazards observed.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: SLEEPY HOLLOW CARE HOME
FACILITY NUMBER: 435202645
VISIT DATE: 12/21/2023
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The following documents were submitted to the San Bruno Adult and Senior Care Program San Jose Unit in September 2023 per request from LPA Monter:
1) LIC 308 - Designation of Administrative Responsibility
2) LIC 400 - Affidavit Regarding Client/Resident Cash Resources
3) LIC 402 - Surety Bond
3) LIC 500 - Personnel Summary
4) LIC 610D - Emergency Disaster
5) Copy of Lease Agreement
6) Administrator's Certificate

Staff and resident files reviewed.

Exit interview conducted with Licensee/Administrator. A copy of this report provided for facility records.

No deficiencies cited.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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