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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202776
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:59:13 PM

Document Has Been Signed on 10/29/2024 02:59 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:NORSEMAN ADULT RESIDENTIAL FACILITY INCFACILITY NUMBER:
435202776
ADMINISTRATOR/
DIRECTOR:		RODOLFO VALENZUELAFACILITY TYPE:
735
ADDRESS:2435 RIDGEGLEN WAYTELEPHONE:
(408) 770-3448
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 4CENSUS: 4DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Cecilia Valenzuela AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPAs) Marcela Yanez and Manuel Monter conducted an unannounced Required 1 Year visit and met with Cecilia Valenzuela, Administrator/Licensee.

During visit, LPAs toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days.

LPAs toured 4 resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. LPA tested the smoke detectors in the hallway to function properly when tested. LPAs toured resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperature in the bathroom measured with thermometer at 118.0 degrees F.

LPAs toured the outside area and found the exits to be clear of obstructions. LPAs observed fire extinguisher was last serviced on 10/17/2024. LPA reviewed Fire and Earthquake log was last conducted on 10/04/2024

LPAs reviewed resident records for 3 residents, Centrally Stored Medication Log, and P&/I. LPAs reviewed 4 staff records.

No deficiency were cited as per California Code of Regulations Title 22. This report was reviewed with Cecilia Valenzuela and a copy of this report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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