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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708102
Report Date: 03/01/2023
Date Signed: 03/01/2023 12:01:16 PM


Document Has Been Signed on 03/01/2023 12:01 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:MERTZ CARE HOMEFACILITY NUMBER:
430708102
ADMINISTRATOR:MERTZ, ELVIRAFACILITY TYPE:
740
ADDRESS:2715 MCLAUGHLIN AVENUETELEPHONE:
(408) 483-2748
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 2DATE:
03/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Rogeline White JimenezTIME COMPLETED:
12:04 PM
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Licensing Program Analyst Ryker Heberle (LPA) arrived at the facility unannounced to conduct a Case Management - Other visit and met with Administrator Rogeline White Jimenez.

The purpose of the visit was to deliver an immediate exclusion letter to exclude an employee (S1) associated to the facility. LPA toured the facility and verified that S1 was not on the premises.

The immediate exclusion letter was handed to Administrator Rogeline White Jimenez.

LPA advised the facility to go through their facility roster on Guardian and to disassociate individuals who are no longer employed at the facility.

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

This report was reviewed with Administrator Rogeline White Jimenez and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
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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