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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200333
Report Date: 12/10/2021
Date Signed: 12/10/2021 11:31:18 AM

Document Has Been Signed on 12/10/2021 11:31 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MANTE BOARD & CARE HOMEFACILITY NUMBER:
275200333
ADMINISTRATOR:SAMSON Z. MANTEFACILITY TYPE:
735
ADDRESS:1553 CUPERTINO WAYTELEPHONE:
(831) 229-4819
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 6CENSUS: 3DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Julia SamsonTIME COMPLETED:
11:44 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Julia Samson.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed there to be a visitor screening area. LPA Marrufo observed 1 out of 1 resident bathrooms had hand washing signs and available soap and paper towels. The facility hallways had COVID-19 related posters. LPA Marrufo observed a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a PPE supply of at least 30 days.

The facility exits were clear of obstructions.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Licensee Julia Samson and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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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