<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202896
Report Date: 06/13/2023
Date Signed: 06/13/2023 11:47:49 AM

Document Has Been Signed on 06/13/2023 11:47 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 HOME 2FACILITY NUMBER:
435202896
ADMINISTRATOR:NIJJAR, MANJINDERFACILITY TYPE:
735
ADDRESS:2742 CARASTON WAYTELEPHONE:
(408) 341-5254
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
06/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Manjinder NijjarTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Pre-Licensing visit and met with Administrator Manjinder Nijjar.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed the kitchen area. The first aid kit was observed and found to be complete. LPA Marrufo observed medications and resident records to be stored in locked cabinets. LPA Marrufo observed a perishable food supply of at least two days and a non-perishable food supply of at least 7 days.

LPA Marrufo toured the facility bathroom and observed there to be available soap and paper towels. The bathroom water temperature measured at 112 F.

LPA Marrufo observed 4 out of 4 resident bedrooms. Each bedroom has functioning lights, clothing storage areas, and functioning smoke detectors. The facility carbon monoxide detector functioned properly when tested.

The outdoor area was toured and the outdoor exit was observed to be free of obstructions.

LPA Marrufo reviewed the Personal & Incidental Money Log with Administrator Nijjar and found it to be complete. The Centrally Stored Medication Logs, Resident Records, and Staff Records were reviewed and found to be complete. The Emergency Disaster Drill Log was reviewed and the last recorded drill was conducted on 04/09/2023.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Manjinder Nijjar and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1