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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202891
Report Date: 04/19/2023
Date Signed: 04/19/2023 04:57:29 PM

Document Has Been Signed on 04/19/2023 04:57 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:RGK HOME CAREFACILITY NUMBER:
435202891
ADMINISTRATOR:CRUZ, RAVENAL D.FACILITY TYPE:
740
ADDRESS:274 CLEARPARK CIRCLETELEPHONE:
(408) 420-7262
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 5DATE:
04/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ravenal CruzTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced pre-licensing inspection visit, and met with Licensee (LNS) Ravenal Cruz.

LPA toured the facility inside and out with LNS. Personal Rights posters and Administrator Certificate were observed posted at facility. Screening station with masks, hand sanitizer, gloves, thermometer and visitor log book was observed at the main entrance. 3 residents and 3 staff were observed in facility.

Living room, kitchen, dinning room and two restrooms were inspected. Three shared resident bedrooms, and laundry room were inspected. Two staff live-in rooms and one small off were observed in facility. First Aid Kit was observed in the facility. Non-skid mats and Bar were observed in one restroom. One of the restrooms was observed Bar, but without non-skid mat. LNS put a new non-skid mat in the restroom immediately.

Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 108 degree F in facility. Temperature of freezer was observed at -10 degree F, and temperature of refrigerator was observed 36 degree F.

Fire extinguisher was serviced on 1/23/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by LNS, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. All the bed rooms were observed with screens.

LNS stated the staff are all fully vaccinated and done with booster. LPA discussed the Infection Control Plan with LNS. Component III orientation was conducted with LNS. Exit interview was conducted with LNS. This report was provided to LNS for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023
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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