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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202891
Report Date: 04/03/2024
Date Signed: 04/04/2024 07:59:07 AM


Document Has Been Signed on 04/04/2024 07:59 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:RGK HOME CAREFACILITY NUMBER:
435202891
ADMINISTRATOR:LAZARO, MARY GRACE V.FACILITY TYPE:
740
ADDRESS:274 CLEARPARK CIRCLETELEPHONE:
(408) 420-7262
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 6DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Mary LazaroTIME COMPLETED:
04:31 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced inspection visit, and met with Administrator (ADM) Mary Lazaro.

LPA observed 3 staff and 3 residents in the facility, and 3 residents went out to the day program. LPA reviewed 3 resident files and 3 staff files.

LPA toured the facility inside and out with ADM. License, Personal Rights posters and Administrator Certificate were observed posted at 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 office were observed in facility. First Aid Kit, flash lights, and night lights were observed in the facility. Non-skid mats and bar were observed in restrooms

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 110 degree F in facility. Temperature of freezer was observed at 0 degree F, and temperature of refrigerator was observed 38 degree F.

Fire extinguisher was serviced on 12/13/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, 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. The last time the facility conducted the emergency drill was 4/1/2024.

No citation noted for today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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