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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202942
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:26:07 PM

Document Has Been Signed on 12/04/2024 03:26 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:GRETCHEN RESIDENTIAL CARE HOME, INC.FACILITY NUMBER:
435202942
ADMINISTRATOR/
DIRECTOR:		ESTOESTA, DAISYFACILITY TYPE:
740
ADDRESS:1716 BERRYWOOD DRIVETELEPHONE:
(408) 930-7565
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 4DATE:
12/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Applicant Daisy EstoestaTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On 12/04/2024 at 8:55 AM LPA Marcela Yanez conducted an unannounced Pre-licensing Inspection for a change of ownership. LPA met with Applicant, Daisy Estoesta.The home currently has 4 residents. Which is approved for age 60 and over. Fire Clearance for 6 Non-Ambulatory residents in rooms 2-5 Room 1 is for staff only, no hospice waiver on file, Dementia plan submitted.

LPAs toured the facility inside and out. The facility is equipped with 8 smoke and carbon monoxide detectors in working condition. Fire extinguisher observed in the home which was serviced on 04/24/2024. The kitchen, dining and living room were observed in good repair. The home is equipped with a Pull fire alarm system which was serviced on 04/24/2024

Kitchen was equipped but not limited to microwave, working stove and refrigerator temperature measured at 37 degrees F and freezer 0 degrees F. Kitchen water measured with thermometer at 112.1 degrees F. Knives and toxics were locked in cabinet. 2-day perishable and 7-day non-perishable food were observed in the kitchen. A garage was observed during inspection with laundry area and staff refrigerator and area being used as office.

Resident bedrooms were observed in good repair, furnished, with clean linens and adequate lighting. 3 Bathrooms were observed clean and equipped with grab bars and non skid mats. The water temperature range for facility bathrooms were measured with thermometer at 108.8 to 110.1 degrees F.

Centrally stored medication cabinet with first aid kit that was complete with gauze, tape, tweezers and first aid guide was observed locked. All outdoor and indoor passageways including ramp in backyard were observed clear and free of obstruction. The backyard was inspected, no bodies of water observed.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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: GRETCHEN RESIDENTIAL CARE HOME, INC.
FACILITY NUMBER: 435202942
VISIT DATE: 12/04/2024
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During inspection LPA observed a locked shed that is being used for storage and not a living quarters.

Component III orientation was completed with applicant.

No issues noted during this pre-licensing inspection.

LPAs 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 Applicant, Daisy Estoesta and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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