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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200459
Report Date: 11/03/2022
Date Signed: 11/03/2022 04:07:05 PM

Document Has Been Signed on 11/03/2022 04:07 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: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:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Robert CervantesTIME COMPLETED:
04:15 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 toured the facility inside and out. LPA observed the visitor screening area. LPA Marrufo observed a 30-Day supply of PPEs. LPA observed a a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. LPA Marrufo observed the bathrooms to have available soap, paper towels, and hand washing signs.

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

This report was reviewed with Robert Cervantes and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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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