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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202876
Report Date: 01/27/2024
Date Signed: 01/27/2024 04:55:58 PM


Document Has Been Signed on 01/27/2024 04:55 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:FAMILY SENIOR CARE HOME IFACILITY NUMBER:
435202876
ADMINISTRATOR:BAUTISTA, ELIZABETHFACILITY TYPE:
740
ADDRESS:2898 GLEN FROST COURTTELEPHONE:
(408) 802-7727
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 4DATE:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator, Elizabeth BautisaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Elizabeth Bautisa. LPA Rai observed 2 staff and 4 residents at the facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas.

LPA Rai toured the resident bedrooms. 4 out of 4 resident bedrooms had available bedding, drawers, and functioning lights.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.1F - 105.4F. The water temperature in the kitchen sink was 107.1F.

Fire extinguisher was observed and inspected on 6/2/2023.

This annual inspection will be completed at a later date.

This report was reviewed with Administrator (ADM) Elizabeth Bautisa. A copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024
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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