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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202862
Report Date: 07/20/2022
Date Signed: 07/20/2022 12:27:19 PM

Document Has Been Signed on 07/20/2022 12:27 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:HANSELL VILLAFACILITY NUMBER:
435202862
ADMINISTRATOR:PAREDES, FREDERICFACILITY TYPE:
740
ADDRESS:5343 HANSELL DRIVETELEPHONE:
(408) 802-0215
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 4DATE:
07/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:PAREDES, FREDERICTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's pre-licensing visit and met with Administrator Frederic Paredes and Arman Guba, and Licensee Gary Cornelia.

There are currently residents in care. There are 4 bedrooms and 2 bathrooms. Facility has an approved fire clearance for 5 non-ambulatory and 1 bedridden.

LPA toured the facility inside and outside to include the living room, resident rooms, bathrooms, kitchen, garage, and backyard. Residents rooms are equipped with proper furniture and lighting. Bedding and linens are available to the residents and observed clean. Bathrooms are equipped with grab bars, nonskid floors, hygiene supplies, and toiletry. Facility is equipped with cups, plates, utensils, and cooking supplies. Hot water temperature was measured at 110.8 degrees Fahrenheit. The facility temperature was maintained between 68 degrees to 75 degrees Fahrenheit.

LPA observed 2 days worth of perishables and 7 days worth of nonperishable. Refrigerator temperature was maintained at 40 degrees Fahrenheit. Freezer temperature was maintained at 1 degree Fahrenheit.

The medication cabinet and sharp objects was observed locked. LPA observed first aid kit with the following supplies: bandages, scissors, tweezers, and thermometer.

LPA reviewed the personnel file. Staff are fingerprint cleared. Resident records was reviewed to include the centrally stored medication records with residents medications.

See LIC812-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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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: HANSELL VILLA
FACILITY NUMBER: 435202862
VISIT DATE: 07/20/2022
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Facility is equipped with smoke detectors, carbon monoxide detector, and fire extinguisher. Hallway and passageways were observed free of obstruction. Fireplace observed screened.

The following posters observed to include personal rights, if you see something say something, ombudsmen, resident right to counsel, emergency disaster plan, facility sketch, and theft and loss policy.

Comp III is being waived because the applicant has been an Administrator since 2006.

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 Frederic Paredes and Arman Guba and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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