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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202837
Report Date: 02/02/2022
Date Signed: 02/03/2022 07:19:24 AM

Document Has Been Signed on 02/03/2022 07:19 AM - 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,
, CA
FACILITY NAME:NIJJAR HOMEFACILITY NUMBER:
435202837
ADMINISTRATOR:NIJJAR, MANJINDER K.FACILITY TYPE:
735
ADDRESS:3661 CADWALLADER AVETELEPHONE:
(408) 341-5254
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 4DATE:
02/02/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Amarvir NijjarTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPA) Marybeth Donovan arrived unannounced to conduct a Pre-Licensing visit. LPA met with Amarvir Nijjar.

There is currently 4 residents living at the facility. The facility has an approved fire clearance for 6 capacity.

LPA toured the facility inside and outside including the entry point, living room, dining room, kitchen, bedrooms, bathrooms, and patio. Resident rooms were equipped with proper furniture and lighting. Bedding and linens are available to the residents and observed to be clean. Bathrooms was equipped with hygiene supplies. Hot water temperature was measured at 107.6 and 106.9 degrees Fahrenheit in hall bathrooms. LPA observed a minimum of 2 day perishable food supply and 7 day nonperishable food supply. Fresh fruit of bananas, apples and cutties were observed. Facility is equipped with cups, plates, utensils, and cooking supplies.

Medications are secured in a locked cabinet in the kitchen. LPA observed first aid kit with the following supplies: bandages, scissors, tweezers, and thermometer.

LPA observed knives, sharp objects, toxins and cleaning supplies in a locked cabinet in the laundry room.

LPA reviewed 2 resident files and 3 staff files. Staff files all consist of Personal Record, Health Screening with TB Information, First Aid Certification and Training.

Component III completed.

Continue on LIC-809C
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: NIJJAR HOME
FACILITY NUMBER: 435202837
VISIT DATE: 02/02/2022
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No issues noted during this Pre-Licensing inspection.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Amarvir Nijjar Group Home Manager and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC809 (FAS) - (06/04)
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