435202906-9-20-2023-26-AS-CDOS-CVUNWC-20230920104919

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202906
Report Date: 09/20/2023
Date Signed: 09/20/2023 10:49:26 AM

Document Has Been Signed on 09/20/2023 10:49 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:	SPENCER ADULT CARE HOME		FACILITY NUMBER:	435202906
ADMINISTRATOR:	TEODORO, ANELISE		FACILITY TYPE:	735
ADDRESS:	9055 SPENCER CT		TELEPHONE:	(408) 393-8075
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY: 6		CENSUS: 6	DATE:	09/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Anelise Teodoro		TIME COMPLETED:	10:55 AM

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) Christine Dolores arrived unannounced to conduct the facility's pre-licensing visit. LPA met with Administrator (ADM), Anelise Teodoro. The facility has an approved fire clearance for 4 ambulatory and 2 non-ambulatory. During visit, LPA toured the facility with ADM to include the living room, dining room, kitchen, family room, backyard, garage, bathroom, resident bedrooms, and staff living quarters. All fire exits were free and clear of obstruction. Facility is equipped with an operable carbon monoxide detector. Facility temperature maintained at 70 degrees Fahrenheit. The entrance contains posters on the wall to include, if you see something say something, facility sketch, visitor policy, personal rights, and COVID-19 related posters. Kitchen equipped with utensils, plates, bowls, and cups. Sharp objects, disinfectants, and chemicals observed locked. LPA observed a hand washing sign. Facility has at least 7 days worth of non-perishables foods. The cabinet with non-perishable foods may be locked for the safety of residents and staff during aggressive behaviors. Residents are given access to the non-perishable foods cabinet, if needed. Facility has at least 2 days worth of perishable foods. Refrigerator temperature maintained at 41 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Facility has a complete first aid kit to include bandages, gauze, scissors, tweezers, thermometer, and manual. Medication cabinet observed locked. SEE LIC809-C.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: SPENCER ADULT CARE HOME	FACILITY NUMBER: 435202906
	VISIT DATE: 09/20/2023

NARRATIVE

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Backyard's emergency exit route observed free and clear of obstruction. Garage is equipped with another refrigerator and freezer that contains additional food storage. Cleaning solutions and laundry detergent observed locked.

Bathroom is equipped with hygiene products, paper towels, toilet paper, and lidded trash bin. Shower observed with grab bars and non-slid floors. Hot water temperature maintained at 108 degreed Fahrenheit.

3 out of 3 resident bedrooms contained a bed, client linens, a dresser for each resident, a night stand, chairs, and lighting.

Facility has an infection control plan and emergency disaster plan. Each resident's emergency go bag contains items not limited to a flash light, non-perishable foods, clothing, hygiene products, and emergency forms.

COMP III completed with Administrator.

No issues noted during this pre-licensing inspection.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Administrator, Anelise Teodoro and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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