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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202760
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:34:12 PM

Document Has Been Signed on 09/08/2023 03:34 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:NORTH STAR RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202760
ADMINISTRATOR:LIRA, ARLENE MARY AGONOYFACILITY TYPE:
735
ADDRESS:1617 ADRIAN WAYTELEPHONE:
(408) 258-8618
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrator Arlene LiraTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Arlene Lira.

LPA toured the facility inside out which included; the Living room, kitchen, dinning room, activity room, two bathrooms, laundry area 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 locked medication cabinet, locked knives drawer, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 77 degree F, and hot water temperature was measured to range from 108 F to 110 F in the facility restrooms.

Fire extinguisher was serviced in September 7 2023. The facility has smoke and carbon monoxide detectors. Smoke detectors was tested by facility staff, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last fire drill was conducted on 09/04/2023 and the last earthquake drill was conducted on 09/05/2023.

LPA reviewed facility records for 2 staff and 2 residents. LPA reviewed 2 resident medications and centrally stored medication records. LPA reviewed two residents P & I money. 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 Administrator Arlene Lira and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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