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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294315
Report Date: 03/13/2025
Date Signed: 03/13/2025 05:25:58 PM

Document Has Been Signed on 03/13/2025 05:25 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:KEENE KARE IIIFACILITY NUMBER:
435294315
ADMINISTRATOR/
DIRECTOR:
GAMBOA, ABIGAILFACILITY TYPE:
740
ADDRESS:4629 ROYAL FOREST COURTTELEPHONE:
(408) 616-0615
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 2DATE:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Cristina BanagoTIME VISIT/
INSPECTION COMPLETED:
11:26 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Cristina Banago. LPA toured the facility inside and out with ADM. One staff and Two residents were observed in the facility. License, personal rights posters, and Administrator Certificate were observed posted at the main entrance.

LPA reviewed one resident file and one staff file.

Living room, family room, kitchen, dinning room and two restrooms were inspected. 4 bedrooms, 1 master bedroom, laundry room, and garage were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet was observed locked. Knives closet were observed locked. Dish washing solution closet under the sink in the kitchen was observed unlocked. ADM locked it immediately during the inspection. Room temperature was at 68 degree F, and hot water temperature was at 107 degree F in facility. The temperature of the refrigerator was at 33 degree F, and the temperature of the freezer was at 0 degree F. The fire extinguisher was observed expired. The facility staff bought a new fire extinguisher and install it before LPA finished the annual inspection.

The facility was equipped with fire alarm system, and carbon monoxide detectors. Fire alarm and carbon monoxide detectors were tested by ADM and they were working. First aid box, flash light and nigh lights were observed in the facility.

Front yard and backyard were inspected. There was no obstruction to block the walkways. One storage room was observed at the back yard.

No citation noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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