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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200751
Report Date: 09/11/2024
Date Signed: 09/11/2024 03:04:36 PM

Document Has Been Signed on 09/11/2024 03:04 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:MUNA'S RESIDENTIAL CARE HOME IFACILITY NUMBER:
435200751
ADMINISTRATOR/
DIRECTOR:		EMAD QADDURAFACILITY TYPE:
735
ADDRESS:4232 INDIGO DR.TELEPHONE:
(408) 979-9265
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: DATE:
09/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Licensee/ Administrator, Emad QadduraTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez conducted a case management visit to follow up on the status of a resident R1 who left the day program unsupervised and has not returned to the facility. LPAs met with Licensee/Administrator, Emad Qaddura and stated the purpose of today's visit.

The facility is a level 3 where residents are overseen by San Andreas Regional Center (SARC). LPAs observed 5 residents and 2 staff at the facility.

LPAs interviewed 2 staff including Licensee/Administrator. At this time, resident R1 has not returned to the facility and day program. Licensee/Administrator is in contact with local law enforcement agency and R1's family.

LPAs obtained copies of R1's records which include but not limited to R1's LIC 602 Physician's Report, Appraisal/Needs and Services Plan and Individual Program Plan (IPP).

Licensee/Administrator stated he will provide updates on the status of R1 to the Department.

LPAs stated for Licensee/Administrator to inform residents' day program about any changes in residents' physical, mental, emotional and social functioning.

LPAs determined that this case management require further investigation to obtain additional information.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee/Administrator, Emad Qaddura and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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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