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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202837
Report Date: 04/10/2024
Date Signed: 04/10/2024 10:22:15 AM

Document Has Been Signed on 04/10/2024 10:22 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NIJJAR HOMEFACILITY NUMBER:
435202837
ADMINISTRATOR/
DIRECTOR:
NIJJAR, MANJINDER K.FACILITY TYPE:
735
ADDRESS:3661 CADWALLADER AVETELEPHONE:
(408) 341-5254
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 4DATE:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Manjinder K. NijjarTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Manjinder K. Nijjar. During the visit, LPA observed 0 residents and 1 staff.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the home, LPA observed the window directly across from the kitchen had a square glass on the outside covering a hole. LPA also observed the window screen adjacent to the hole, had a hole as well. (Photographs were taken.) ADM stated the small portion of glass was damaged when a resident was having a behavior. ADM stated the square glass was placed for the safety of the residents. ADM stated she was speaking to contractors to have the window fixed. ADM stated the screen adjacent to it is going to be replaced this weekend.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 112 degrees F in resident bathrooms.

Fire extinguisher was serviced in July 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on February 28, 2024.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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: NIJJAR HOME
FACILITY NUMBER: 435202837
VISIT DATE: 04/10/2024
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LPA reviewed facility records for 3 staff and 4 residents. LPA conducted interviews with 1 staff and 1 residents. The other residents were attending Day Program during LPA's visit.

LPA requested to see the current Centrally stored medication records. ADM searched for the current records but could not find them. ADM stated she had the records for February, but not for March or April. ADM called her lead staff. ADM told LPA that her lead staff did do the March Centrally stored medication records, but could not find them. ADM stated she would send a copy of the March centrally stored medication records to LPA. ADM filled out the April Centrally stored medication log for 4 residents during LPA's visit.

No deficiencies are being cited during today's visit. Two technical violations were given. This report was reviewed with Administrator Manjinder K. Nijjar and a copy of the signed report was provided.

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END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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