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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200751
Report Date: 10/30/2024
Date Signed: 10/31/2024 08:08:04 AM

Document Has Been Signed on 10/31/2024 08:08 AM - 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: 6DATE:
10/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:39 AM
MET WITH:Emad QadduraTIME VISIT/
INSPECTION COMPLETED:
12:57 PM
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Licensing Program Analysts(LPAs) Steve Chang and Mita Partoza conducted an unannounced case management inspection visit and LPAs met with Administrator(ADM) Emad Qaddura.

LPAs stated the purpose of the visit is to conduct a case management to address the incident when resident (R1) eloped while attending the day program on 9/3/2024.

LPAs toured the facility inside and outside such as but not limited to the kitchen, dining, living room and resident room and bathroom and staff room. LPAs observed no sharps, knives and medications and observed them to be locked and not accessible to resident. LPAs observed chemicals are locked and not accessible to residents. Facility is maintained and sanitary. Walkways and hallways are free from obstructions.

The facility has 6 residents who are ambulatory and are intellectually disabled. LPAs observed 5 out of 6 residents are not present. LPA interviewed staff and R1. R1 resides at the facility and is currently not attending a day program.

LPAs requested LIC/ADM to provide updated appraisal needs and service plan for R1 based on the discharge instruction from the hospital, progress notes, after the incident and a written plan of action to prevent the incident from occurring. .

No deficiencies were cited during today's visit. Exit interview was conducted with administrator Emad Qaddura. A copy of the report was provided.

End of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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