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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202667
Report Date: 02/21/2024
Date Signed: 02/21/2024 03:42:53 PM


Document Has Been Signed on 02/21/2024 03:42 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:AT HOME SENIOR CARE IIFACILITY NUMBER:
435202667
ADMINISTRATOR:SAZON, DEBBIEFACILITY TYPE:
740
ADDRESS:825 GAIL AVETELEPHONE:
(408) 738-1400
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:6CENSUS: 5DATE:
02/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Debbie SazonTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Debbie Sazon.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the facility kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least 7 days. The facility first aid kit was observed and found to be complete.

LPA Marrufo toured 6 out of 6 resident bedrooms and observed each bedroom to have available bedding and dresser drawers and working lights. LPA Marrufo tested the facility smoke detector system and found it to function properly when tested. 7 out of 7 resident bathrooms had water temperatures from 105 F to 110 F.

LPA Marrufo toured the outside area and the exits were found to be clear of obstructions.

LPA Marrufo reviewed resident and staff records and found them to be complete.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Debbie Sazon and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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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