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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200608
Report Date: 10/26/2022
Date Signed: 10/26/2022 05:00:20 PM

Document Has Been Signed on 10/26/2022 05:00 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:MAYFLOWER CARE HOMEFACILITY NUMBER:
435200608
ADMINISTRATOR:ESLAVA, ISABEL M.FACILITY TYPE:
740
ADDRESS:668 APACHE COURTTELEPHONE:
(408) 972-1999
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 4DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Isabel EslavaTIME COMPLETED:
05:03 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 10/26/2022. LPA met with facility Administrator Isabel Eslava (Admin) and began the inspection.

LPA toured the facility, including hallway, kitchen, living room, all bedrooms, 2 bathrooms, dining room, back yard, office, and garage. LPA was not screened for symptoms and temperature was not taken. Admin informed LPA that the facility does not have a guest sign in process. Facility caregiver was not observed to be wearing a mask. Admin confirmed that all staff and all residents have been vaccinated.

Facility noted to have a 30 day supply of PPE. No prohibited items noted in resident rooms. All rooms in facility noted to be clean and well maintained. Hand sanitizers and soap were observed to be available. Paper towels not observed in resident bathrooms. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to have been inspected in May of 2022.

Smoke/carbon monoxide detectors were tested and observed to be operational. Proper hand washing signs were not observed in the facility bathrooms. Water temperature observed to be 105.3 *F in facility bathroom. Facility temperature observed to be 69*F. No social distancing signs were observed to be posted in any public areas.

No deficiencies cited during today's visit. Advisory notes issued. This report was reviewed with Administrator Isabel Eslava, and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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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