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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200666
Report Date: 07/09/2024
Date Signed: 07/09/2024 03:17:12 PM

Document Has Been Signed on 07/09/2024 03:17 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:VALDEZ CARE HOMEFACILITY NUMBER:
435200666
ADMINISTRATOR/
DIRECTOR:
CARRANZA, HELEN V.FACILITY TYPE:
735
ADDRESS:2565 SUGAR PLUM DRIVETELEPHONE:
(408) 270-2613
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Edna MamuyacTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Edna Mamuyac, Care Giver.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area and observed the kitchen to have a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA Marrufo observed the facility first aid kit and found it to be complete.

LPA Marrufo toured 3 out of 3 resident bedrooms. Each bedroom had functioning lights and available bedding and clothing storage areas. LPA Marrufo tested one out of one carbon monoxide detectors and found it to function properly when tested. LPA Marrufo tested the smoke detectors in the 3 bedrooms and in the hallways and all smoke detectors functioned properly when tested.

LPA Marrufo toured two out of two resident bathrooms and found each bathroom to have available soap and paper towels. The bathroom sinks had water temperatures at 117 F and 119 F.

LPA Marrufo toured the outside area and found the outdoor exits were clear of obstructions.

LPA Marrufo reviewed 4 out of 4 Personal and Incidental Money Logs and found them to be balanced. LPA reviewed 5 out of 5 Centrally Stored Medication and Destruction Records and found them to be complete. LPA Marrufo reviewed 5 out of 5 resident records and 5 staff records and found them to be complete. The Emergency Disaster Drill Log indicates the last recorded drill was conducted on 05/11/2024.

No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Care Giver Edna Mamuyac and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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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