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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707868
Report Date: 12/10/2021
Date Signed: 12/10/2021 04:13:34 PM

Document Has Been Signed on 12/10/2021 04:13 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:FLORENCE RESIDENTIAL CARE HOME #2FACILITY NUMBER:
430707868
ADMINISTRATOR:PERLA DIMALANTA ZEIJNALIFACILITY TYPE:
735
ADDRESS:135 NORTH 8TH STREETTELEPHONE:
(408) 293-0362
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 10CENSUS: 9DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Allan OnofreTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Alan Onofre.

During visit, LPA Marrufo observed there to not be a visitor screening area or any log to record visitor symptoms and temperatures. LPA Marrufo observed the facility did not have a PPE supply of at least 30 days. LPA Marrufo observed a bag of gloves and 2 masks. 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 staff Allan Onofre not wearing a mask during visit.

LPA Marrufo observed COVID-19 related signs throughout the facility. LPA Marrufo toured the inside and outside of the facility. Facility bathrooms had hand washing signs and available soap and paper towels.

LIC9102 Technical Advisories were issued.

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

This report was reviewed with Allan Onofre 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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