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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707097
Report Date: 07/17/2026
Date Signed: 07/17/2026 04:51:08 PM

Document Has Been Signed on 07/17/2026 04:51 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:PARK AVENUE ADULT RESIDENTIAL FACILITIESFACILITY NUMBER:
430707097
ADMINISTRATOR/
DIRECTOR:		EUSTAQUIO,CECILIAFACILITY TYPE:
735
ADDRESS:1992 & 1998 PARK AVENUETELEPHONE:
(408) 241-0605
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 12CENSUS: 11DATE:
07/17/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Cecilia EustaquioTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (ADM) Cecilia Eustaquio. The purpose of the visit was to follow up on citations issued on 06/23/2026.

During visit, LPA Marrufo observed that there was an adult individual living in Room “BD” in the facility house located at 1992 Park Avenue. LPA Marrufo asked the individual for his/her identification. The individual’s identification indicated the other facility house, 1998 Park Avenue, as his/her residential address. The individual stated he/she is paid $600 a month to be a handyman at the facility. He/She stated to work on an on-call basis and sleeps in Room “BD” when he comes to the facility to work on repairs. Room “BD” in the facility floor plan is designated as a staff room. LPA toured Room “BD” and observed there to be a bed, clothes, a guitar, food, books, and other belongings. The individual stated he/she slept in the bed last night and stayed the night in the room last night. He/she stated he stays the night in the room two to three nights per week.

The individual who stated he/she is a handyman is not background checked or associated to the facility employee roster.

LPA observed that the facility floor plan for 1992 Park Avenue shows a room between Room “BD” and Room “CD” that does not exist. LPA observed that the doorway between Rooms “BD” and “CD” had been sealed shut.

See LIC809-C page for more information. Page 1 of 2.
Christine Kabariti
David Marrufo
DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 07/17/2026 04:51 PM - It Cannot Be Edited


Created By: David Marrufo On 07/17/2026 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2026
Section Cited
CCR
80022(b)(7)

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80022 Plan of Operation (b) The plan and related materials shall contain the following: (7) A sketch of the building(s) to be occupied, including a floor plan which describes the capacities of the buildings for the uses intended, room dimensions, and a designation of the
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Licensee agrees to submit to CCL by 07/24/2026 an updated facility floor plan of the entire facility, including both houses, that accurately describes the capacities of the buildings for the uses intended, room dimensions, and a designation of the rooms to be
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rooms to be used for nonambulatory clients, if any. This requirement was not met as evidenced by: Licensee did not ensure that the facility floor plan accurately described 1992 Park Avenue; the floor plan described a room which is not present in the house and the floor plan does not designate the intended use of one of the bedrooms (Bedroom “CD”) that is currently being used to reside staff S1 and S2, which poses a potential safety risk to residents in care.
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used for nonambulatory clients, if any. The floor plan should remove the non-existent room in 1992 Park Avenue that is shown in the current floor plan and should designate the intended use of the bedroom next to the living room in 1992 Park Avenue

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2026 04:51 PM - It Cannot Be Edited


Created By: David Marrufo On 07/17/2026 at 03:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2026
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: Licensee did not ensure
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Licensee agrees to submit a plan of correction by 07/18/2026 stating how the licensee will ensure that all the cabinet doors in the kitchen of 1992 Park Avenue have knobs installed. Once the knobs are installed, licensee agrees to submit photographic evidence of the installed knobs.
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that the cabinets in the kitchen in 1992 Park Avenue had knobs, which poses a potential safety risk to residents in care.
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Type A
07/18/2026
Section Cited
CCR80087(g)

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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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Licensee agrees to submit a plan of correction by 07/18/2026 stating how the licensee will ensure that all disenfectants, cleaning solutions, poisons, and other items that could pose a danger if readily available to clients, including rat traps and metal-tipped darts, shall be stored where they are
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Licensee did not ensure that disinfectants, cleaning solutions, poisons, rat traps, and metal-tipped darts were stored in a place that is inaccessible to clients, which poses an immediate health and safety risk to residents in care.
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inaccessible to clients. Once these items are moved to a new location that is inaccessible to clients, the licensee shall submit photographic evidence that they are secured.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
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: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097
VISIT DATE: 07/17/2026
NARRATIVE
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LPA Marrufo interviewed staff S1 and S2. They both stay in Room “CD.” Both S1 and S2 are associated to the facility, per the Guardian Employee Roster.

Room “CD” has no designation on the facility floor plan. It is not indicated to be either a staff or resident room.

LPA toured the kitchen in 1992 Park Avenue. The drawers in the kitchen did not have knobs or locks. The drawers contained cleaning supplies and chemicals, including bleach, glass cleaner, bed bug spray, and other cleaning supplies containing chemicals. One of the unlocked cabinets contained two spring-loaded rat traps.

LPA observed the recreation room attached to 1992 Park Avenue. In the recreation room, LPA observed there to be a dart board with metal-tipped darts.

During visit, ADM stated she sleeps in the living room in 1998 Park Avenue. LPA toured the living room and observed there to be a bed, mini refrigerator with Pepsi cans inside, and a desk with a laptop. LPA observed that the wall between the living room and Bedroom 1 was sealed shut. The facility floor plan indicates that there should be a doorway between the living room and Bedroom 1. LPA Marrufo observed there to be three plastic bins with resident medications placed on top of a rolling cart in the living room. The door from the living room to the kitchen was unlocked during visit. The door from the living room to the front of the house was unlocked and opened during visit.

An immediate civil penalty of $500 is being assessed today for failure to obtain a background clearance for a non-client resident. See LIC421BG for more information. An immediate civil penalty of $1,000 is being assessed today for a repeat violation. See LIC421IM for more information.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. This report was reviewed with Licensee/Administrator Cecilia Eustaquio and a copy of this report was provided. Page 2 of 2. END REPORT
NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 07/17/2026 04:51 PM - It Cannot Be Edited


Created By: David Marrufo On 07/17/2026 at 03:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2026
Section Cited
CCR
80019(e)(2)

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80019(e)(2) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record.
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Licensee agrees to submit a plan of correction to CCL by 07/18/2026 stating how the licensee will ensure that all current and non-client residents are background cleared as well as ensuring that the individual residing in Room "BD" is not
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This requirement was not met as evidenced by: Licensee did not ensure that an individual working at the facility as a handyman obtained a California clearance or criminal record prior to residing at the facility, which poses an immediate safety risk to residents in care.
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present at the facility while he/she does not have a background clearance.
Type A
07/18/2026
Section Cited
CCR80086(a)

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80086
Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement was not met as evidenced by: Licensee did not inform
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Licensee agrees to submit a plan of correction to CCL by 07/18/2026 stating why the doorway between the staff rooms in 1992 Park Avenue and the doorway between the living room and Bedroom 1 of 1998 Park Avenue were sealed closed, as well as how the licensee plans to request a fire inspection
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the licensing agency that it had sealed the doorway between both staff rooms in 1992 Park Avenue and the doorway between the living room and Bedroom 1 in 1998 Park Avenue, which poses an immediate safety risk to residents in care.
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from the fire marshall to review the sealed doors and submit a new floor plan and fire clearance once the fire inspection is complete. The plan must also include whether or not the doors will remain sealed and why or why not.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 8
Document Has Been Signed on 07/17/2026 04:51 PM - It Cannot Be Edited


Created By: David Marrufo On 07/17/2026 at 03:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2026
Section Cited
CCR
85087(a)(3)

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 Buildings and Grounds (a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements: (3) No room commonly used for other purposes shall be used as a bedroom for any person. This requirement was not met as evidenced
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Licensee agrees to submit a plan of correction to CCL by 07/18/2026 stating how the licensee/administrator will ensure that the living room in 1998 Park Avenue is not used as a bedroom for any person, including the licensee/administrator.
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by: Licensee did not ensure that licensee/
administrator was not using the living room in 1998 Park Avenue as her own bedroom, which poses an immediate safety risk to residents in care.
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Type A
07/18/2026
Section Cited
CCR80075(k)(1)

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80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the
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Licensee agrees to submit a plan of correction to CCL by 07/18/2026 stating how all resident centrally stored medications will be kept in a safe and locked place this is not accessible to persons other than employees responsble for the supervision of the centrally stored medication.
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centrally stored medication. This requirement was not met as evidenced by: Licensee did not ensure that the medications of three residents were not left unsecured on top of a rolling cart in the facility living room (that the administrator uses as her bedroom), which poses an immediate safety risk to residents in care.
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The licensee agrees to submit photographic evidence of where the medications will be securely stored.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 07/17/2026 04:51 PM - It Cannot Be Edited


Created By: David Marrufo On 07/17/2026 at 03:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2026
Section Cited
CCR
80064(a)(3)

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80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by: Licensee/Administrator did not ensure
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Licensee agrees to submit a plan of correction to CCL by 07/18/2026 stating how she will ensure that she has the knowledge of and ability to comply with applicable law and regulation, including but not limited to, ensuring all non-client residents at her facility were background
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that she had the knowledge and ability to
comply with applicable law and regulation, including, but not limited to, ensuring all non-client residents at her facility were background checked and cleared, ensuring the facility floor plan is accurate, ensuring the facility buildings were not altered prior to notifying the licensing agency, ensuring items that could pose a danger to the residents were stored in a secured location, and ensuring that she was not using the living room of 1998 Park Avenue as her bedroom, which poses an immediate health and safety risk to residents in care.
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 checked and cleared, ensuring the facility floor plan is accurate, ensuring the facility buildings were not altered prior to notifying the licensing agency, ensuring items that could pose a danger to the residents were stored in a secured location, and ensuring that she was not using the living room of 1998 Park Avenue as her bedroom, which poses an immediate health and safety risk to residents in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
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