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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200335
Report Date: 01/09/2025
Date Signed: 01/09/2025 04:04:51 PM

Document Has Been Signed on 01/09/2025 04:04 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:TERESA RESIDENTIAL CARE HOMEFACILITY NUMBER:
435200335
ADMINISTRATOR/
DIRECTOR:
MELDA ANTONIO, JOCELYN PERFACILITY TYPE:
735
ADDRESS:3298 ARQUEADO DRIVETELEPHONE:
(408) 532-1376
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 4DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator Melda Antonio and Designated Administrator Jocelyn PerezTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Melda Antonio, Administrator and Designated Administrator Jocelyn Perez. LPA stated the purpose of the visit.

During visit, LPA Yanez toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days perishable and seven days non-perishable

LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. LPA tested the smoke detectors in the hallway and three resident bedrooms and found the smoke detector to function properly when tested by Staff.. LPA toured one resident bathroom. Bathroom had available soap and paper towels and functioning lights. The water temperature in the bathroom sink measured water temperature with thermometer at 117.3 F. The room temperature measured at 70 degrees F.

LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 02/05/2024 LPA reviewed Fire and Earthquake log was last conducted on 12/05/24

LPA reviewed resident records for 3 out of 4 residents. LPA reviewed 3 staff records and found them to be complete. P and I was also reviewed with Administrator and found to be complete

No deficiency were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Melda Antonio and Designated Administrator Jocelyn Perez and a copy of this report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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