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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202870
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:09:53 PM

Document Has Been Signed on 11/09/2023 03:09 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:DIGNITY CARE HOMEFACILITY NUMBER:
435202870
ADMINISTRATOR:SUNGLAO, BERNARDINO P.FACILITY TYPE:
735
ADDRESS:3899 MARE PLACE CTTELEPHONE:
(909) 205-0891
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 0DATE:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Staff Member Annamarie ZarragaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff Member S1 Annamarie Zarraga . During visit, LPA observed 0 residents and 0 staff. S1 stated the facility just got vendored by SARC on September 20, 2023. S1 stated the facility is currently touring the home to prospective residents and should have 3 residents by December.

LPA toured the facility inside out with S1 which included; the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. LPA observed a shed in the backyard that is being used as a storage shed. There was no obstruction to block the walkways.

LPA observed the medication storage closet, knives storage area, and cleaning product storage area as locked . Room temperature was at 75 degrees F, and hot water temperature was measured at 108 degrees F in both resident bathrooms.

Fire extinguisher was serviced in November 3, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit. The facility has not conducted a drill, as the home remains empty and still does not have residents.

LPA reviewed facility records for 1 staff. LPA interviewed S1. LPA did not review resident records as the home has not had a single resident living in the home.

No deficiencies cited during today's visit. This report was reviewed with Staff Member Annamarie Zarraga and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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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