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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 434700163
Report Date: 06/08/2022
Date Signed: 06/08/2022 01:27:20 PM

Document Has Been Signed on 06/08/2022 01:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:SUMALA HEALTHFACILITY NUMBER:
434700163
ADMINISTRATOR:GUEVARA, ZUSETTEFACILITY TYPE:
300
ADDRESS:3955 ARDEN FARMS PLTELEPHONE:
(669) 220-0755
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: CENSUS: DATE:
06/08/2022
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jason MedinaTIME COMPLETED:
02:15 PM
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Sumala Health on 6/8/2022. Upon arrival, the HCSB analyst identified himself and was greeted by Jason Medina. The proper posting of business hours and license was observed. The analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the analyst discussed the findings of the inspection with Jason and informed the designee that no discrepancies were found. In addition, the designee was provided a printed copy of the LIC 9058 (Applicant/Licensee Rights) form.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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