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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202876
Report Date: 01/04/2023
Date Signed: 01/04/2023 11:56:04 AM

Document Has Been Signed on 01/04/2023 11:56 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:FAMILY SENIOR CARE HOME IFACILITY NUMBER:
435202876
ADMINISTRATOR:BAUTISTA, ELIZABETHFACILITY TYPE:
740
ADDRESS:2898 GLEN FROST COURTTELEPHONE:
(408) 802-7727
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 0DATE:
01/04/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Elizabeth Bautista & Armando GubaTIME COMPLETED:
12:00 PM
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On 1/4/2023 at 10am Licensing Program Analysts (LPA) Simi Rai arrived announced to conduct the facility's pre-licensing visit. LPA met with Licensee Elizabeth Bautista & Armando Guba. There are no clients present on site.
During visit, LPA toured the facility to include the living room, family room, kitchen, garage ,2 bathrooms, 5 bedrooms, dining room and exterior. All fire exit routes were free and clear of obstruction. Toxins observed secured. Facility has an approved fire clearance for 5 non-ambulatory clients and 1 bedridden client.

Facility has a central entry point for symptom screening and temperature check for all clients, staff, and visitors. Bathrooms supplied with hand washing sign, hygiene products, and paper supplies. LPA observed the carbon monoxide detectors to be in working condition. Hot water temperature maintained between 108.9 - 110.3 degrees Fahrenheit. Facility temperature maintained at 70 degrees Fahrenheit. First aid kit supplied with tweezers, bandages, gauze, scissors, and thermometer. Battery operated flashlights observed on-site. Medications will be stored in a locked cabinet. Kitchen observed to have areas to lock sharp supplies. LPA observed the facility to have Personal Protective Equipment (PPE) supplies. The following posters observed to include the emergency telephone numbers, personal rights, RCFE compliant poster, complaint information, Rights of Resident Councils, Personal Rights of Residents in All Facilities, required mask, and facility sketch.

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 Licensee Elizabeth Bautista & Armando Guba and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2023
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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