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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202879
Report Date: 12/13/2023
Date Signed: 12/15/2023 08:38:54 AM

Document Has Been Signed on 12/15/2023 08:38 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:RACHELLE'S HOME IIIFACILITY NUMBER:
445202879
ADMINISTRATOR:ILAGAN, MYLAFACILITY TYPE:
740
ADDRESS:4101 FAIRWAY DRIVETELEPHONE:
(831) 201-4785
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY: 26CENSUS: 17DATE:
12/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Myla IlaganTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Steve Chang and Mita Partoza conducted an unannounced pre licensing inspection, and met with administrator (ADM) Myla Ilagan. LPAs observed 17 residents and 7 staff at facility.

LPAs toured the facility with ADM inside and out. LPA inspected living room, dinning rooms, kitchen. There are 3 common restrooms, staff live-in room, 19 resident rooms in facility. Some bathrooms were observed without non skid pads. ADM stated the facility will put the non skid pad in the bathrooms. Two days perishable foods and seven days non perishable foods were observed sufficient. Room temperature was observed at 71 degree F, hot water temperature was observed at 109 degree F. Temperature of refrigerator was measured at 40 degree F, and temperature of freezer was observed at 0 degree F. Medication cabinet, and cleaning products closet were observed locked. Knives cabinet was observed unlocked. ADM stated the facility will fix this issue. 3 window screens were observed not in good repair. ADM stated the facility will fix this issue.s

Fire extinguisher was serviced on 7/5/2023. The facility is equipped with fire alarm and carbon monoxide detectors. Smoke detector alarm system were tested, and were working fine. First Aide Box was observed in the facility. Night lights was not observed in the hallway. ADM stated the facility will put the night light at the hallway.

Front yard and backyard were inspected. There was no obstruction to block the walkways.Facility last fire and emergency drill was conducted on 12/08/2023. Component III was conducted with ADM.

No citation was issued today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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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