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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707868
Report Date: 12/02/2022
Date Signed: 12/02/2022 04:54:38 PM

Document Has Been Signed on 12/02/2022 04:54 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: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: 10DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Mary-Jane IknerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Mary-Jane Ikner.

During visit, LPA Marrufo observed a 30-day supply of surgical masks. There was one box of surgical gloves, and face shields. The facility did not have any N95 masks or gowns. There was no visitor screening area at the entrance.

LPA Marrufo toured 3 out of 3 resident bathrooms and observed them to have available soap and paper towels.

LPA Marrufo observed the food supply in the kitchen pantries, kitchen refrigerator, and freezer located in the dinning area and found them to have a perishable food supply of at least 2 days and a non-perishable food supply of at least 3 days.

Technical Assistance Notes were created. See LIC9102 forms for more information.

This report was reviewed with Mary-Jane Ikner and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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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