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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707831
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:16:43 PM

Document Has Been Signed on 09/12/2024 04:16 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:LITTERAL HOUSEFACILITY NUMBER:
430707831
ADMINISTRATOR/
DIRECTOR:		CHRISTINA ROSSIFACILITY TYPE:
772
ADDRESS:96 SOUTH 14TH STREETTELEPHONE:
(408) 998-3293
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 14CENSUS: 13DATE:
09/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Christina RossiTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Administrator Christina Rossi. The purpose of the visit was to photograph facility resident Room #4, which is included in a waiver request by the facility to add an additional bed for a total of four residents.

During visit, LPA Marrufo toured Room #4 and took photographs of the room.

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

This report was reviewed with Administrator Christina Rossi and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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