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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200630
Report Date: 04/15/2024
Date Signed: 04/15/2024 04:49:34 PM

Document Has Been Signed on 04/15/2024 04:49 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:MERTZ CARE HOME, INC.FACILITY NUMBER:
435200630
ADMINISTRATOR/
DIRECTOR:		MERTZ, ELVIRAFACILITY TYPE:
735
ADDRESS:2906 CASTLETON DRIVETELEPHONE:
(408) 531-0686
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Rogeline JimenezTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Elvira Mertz, Administrator.

During visit, LPA Marrufo toured the hallway bathroom and observed the water temperature to be at 119 F. The bathroom had available soap and paper towels and had working lights.

LPA Marrufo reviewed the Personal and Incidental Money Logs for all six residents during visit.

LPA Marrufo tested the smoke detectors in 3 out of 3 resident bedrooms, 1 out of 1 living room, 1 out of 1 hallway, and 1 out of 1 kitchen. All smoke detectors functioned properly when tested.

Due to time constraints, the annual inspection visit will need to be completed at a later time.

No deficiencies were cited during visit.

This report was reviewed with Administrator Rogeline Jimenez and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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