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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202776
Report Date: 10/27/2021
Date Signed: 10/27/2021 04:17:24 PM

Document Has Been Signed on 10/27/2021 04:17 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NORSEMAN ADULT RESIDENTIAL FACILITY INCFACILITY NUMBER:
435202776
ADMINISTRATOR:VALENZUELA, CECILIA SANOYFACILITY TYPE:
735
ADDRESS:2435 RIDGEGLEN WAYTELEPHONE:
(408) 770-3448
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 4CENSUS: 4DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:VALENZUELA, CECILIA SANOYTIME COMPLETED:
01:15 PM
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Licensing Program Analyst, Steve Nguyen, conducted an unannounced annual inspection with Administrator VALENZUELA, CECILIA SANOY.

LPA toured facility inside and out. LPA observed: Covid signs are present and in conspicuous vantage points, are exits are free of obstructions, emergency contact for residents were up to date, facility screening protocols were enforce, hand sanitizing station were available throughout facility, medicine cabinet were observed to be locked, paper towers are in use, all rooms in facility are single occupancy, and physical distancing was observed to be in practice.

No citation was issued at this time.

LPA went over report findings with Administrator, VALENZUELA, CECILIA SANOY, for review and a copy was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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