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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202033
Report Date: 08/27/2024
Date Signed: 08/27/2024 12:53:50 PM

Document Has Been Signed on 08/27/2024 12:53 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CCC ARF, INC. DBA NANTUCKET HOME #4FACILITY NUMBER:
435202033
ADMINISTRATOR/
DIRECTOR:		MARIA VALENTINA CRISTOBALFACILITY TYPE:
735
ADDRESS:2917 PENITENCIA CREEK RD.TELEPHONE:
(408) 259-6146
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 3CENSUS: 3DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Nilda Bautista Designated AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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8/27/2024 at 0828, Licensing Program Analyst (LPA) Maria (Mita) Partoza, arrived at the facility to conduct an unannounced required 1 year inspection visit. At the time of arrival no staff were present. LPA was able to reach licensee/administrator Maria Valentina Cristobal. LIC/ADM which stated one of the designated administrator (DADM) Nilda Bautista will be arriving to assist LPA with the annual required inspection. LIC/ADM stated residents are picked up by the day program at 8:00 a.m. and night staff leaves afterwards. LIC/ADM stated she is not able to come to the facility because she was attending a personal training.

The facility currently serves adults ages 18-59 years old who are ambulatory and are developmentally disabled.

At 9:40 a.m. LPA met DADM Nilda Bautista and started the tour of the facility. There were no resident present at the time of the visit. LPA toured the facility inside and outside with DADM, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, backyard and walkways. The temperature inside the home was at 73 degrees F.

LPA with DADM inspected 3 of 3 resident rooms and 1 staff room. LPA inspected 2 of 2 bathrooms. DADM stated no staff sleeps in the facility. LPA observed rooms are organized, sanitary and free from any debris and has sufficient storage for residents' personal belongings. 2 of 2 bathrooms have anti skid floors and grab bars and sufficient supply of paper towels and toiletries. LPA with ADM inspected kitchen, dining, living room, activity room and observed the areas are organized, and free from any debris. LPA did not observed any unlocked knives or sharps in the kitchen and no cleaning supplies were accessible to residents. LPA observed 2 days of perishable and 7 days of non-perishable food. The refrigerator temperature is at 40 degree F and freezer is at 0 degree F. LPA with DADM tested the water temperature with a digital thermometer in bathroom the water measured at 116.7 degree F and the kitchen sink water measured at 124.7 degree F. page 1 of 2 see LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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 2
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: CCC ARF, INC. DBA NANTUCKET HOME #4
FACILITY NUMBER: 435202033
VISIT DATE: 08/27/2024
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LPA discussed and gave DADM technical advisory should the water temperature reaches 125 degree F or higher in the kitchen shall be prominently identified with warning signs.

LPA observed that the facility has smoke and carbon monoxide alarm system that was tested and in good working condition. The facility is equipped with a fire alarm system that connects directly to the fire department. Hallways are free from obstruction. Fire extinguisher was last inspected on 3/25/2024.



LPA and ADM inspected the laundry area and the garage. LPA observed that laundry and cleaning supplies are kept in the garage area in a locked cabinet not accessible to the residents. LPA observed that laundry and dryer machines are in good working condition.

LPA observed the medication cabinet is locked and is not easily accessible. LPA observed first aid kit has a manual, complete first aid supplies and easily accessible to staff.

LPA reviewed the facility file, the facility has one NOC (nocturnal) staff and 2 staff during the day. Facility's fire and earthquake drill training conducted on 1/7/2024, 4/7/2024 and 7/13/2024. LPA requested updated surety bond, LIC 500 and LIC 308 and resident roster. The facility records are current and updated regularly.
LPA reviewed 3 staff record and 3 of 3 resident record. Staff training records were up to date 3 of 3 staff record reviewed with current first aid certifications, clearance and training. Residents files were reviewed to be complete. Residents' centrally stored medication and destruction record (CSMDR) were reviewed. LPA observed medications are labeled, and listed on the CSMDR.

No deficiencies were cited during today's visit based on California Code of Regulation (CCR) Title 22. An exit interview was with designated administrator (DADM) Nilda Bautista. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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