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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200459
Report Date: 11/12/2021
Date Signed: 11/12/2021 03:41:27 PM

Document Has Been Signed on 11/12/2021 03:41 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HOMELIFE RESIDENTIAL CAREFACILITY NUMBER:
435200459
ADMINISTRATOR:JAVIER, JULIUS ERVINFACILITY TYPE:
735
ADDRESS:367 FONTANELLE DRIVETELEPHONE:
(408) 578-6257
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 6DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Robert CervantesTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Robert Cervantes. During visit, LPA Marrufo also spoke with Administrator Julius Javier over the telephone.

LPA Marrufo observed the inside and outside of the facility. LPA Marrufo observed there to be a visitor screening area where visitor's temperatures are check and visitors are asked to fill out a COVID-19 symptom screening form. LPA Marrufo observed 1 out of 1 resident bathroom had hand washing posters. There was available soap and paper towels for residents. LPA Marrufo observed the facility PPE and food supplies. The PPE supplies were sufficient for 30 days and the food supplies included enough perishable foods for 3 days and non-perishable foods for 7 days. LPA Marrufo observed COVID-19 related signs throughout the facility hallways.

LPA Marrufo toured the outside of the facility and observed the exits to be clear of obstruction.

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

This report was reviewed with Administrator Julius Javier and staff Robert Cervantes and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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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