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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200157
Report Date: 10/14/2021
Date Signed: 10/14/2021 10:56:15 AM

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:SANDY'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
435200157
ADMINISTRATOR:ZIPAGAN, AZUCENAFACILITY TYPE:
740
ADDRESS:550 TUSCARORA DRIVETELEPHONE:
(408) 472-2059
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 3DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Azucena ZipaganTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Azucena Zipagan.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed a visitor screening area at the facility entrance. LPA Marrufo observed COVID-19 related signs and posters posted throughout the facility hallways. LPA Marrufo toured two out of two bathrooms and observed there to be available soap and paper towels as well as hand washing guidance posters. LPA Marrufo observed there to be a PPE supply of at least 30-days.


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

This report was reviewed with Administrator Azucena Zipagan and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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