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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200793
Report Date: 03/05/2025
Date Signed: 03/05/2025 06:45:10 PM

Document Has Been Signed on 03/05/2025 06:45 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:NIKKO'S RESIDENTIAL CARE HOME IIFACILITY NUMBER:
435200793
ADMINISTRATOR/
DIRECTOR:		VILLAREAL, MICHELLEFACILITY TYPE:
735
ADDRESS:5724 BLOSSOM AVETELEPHONE:
(408) 972-1792
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 3DATE:
03/05/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
06:06 PM
MET WITH:Stephanie Valera - Designated AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:03 PM
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On March 5, 2025, Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management-other visit to the facility. LPA met with designated administrator (DADM) Stephanie Valera and stated the purpose of the visit is to hand deliver a letter of Order to Licensee/Facility of Immediate Exclusion from Facility of an individual (S1) associated with the facility.

ADM was not in the facility during the time of the visit and staff (S2) called ADM who stated Stephanie Valera and Nicholas Villarreal are the designated administrators (DADMs) in her absence and is authorized to receive and sign the report. DADM stated that S1 did not work at the facility but associated to the facility only. LPA verified that an LIC 308 (Designation of Facility Responsibility) is up to date.

LPA requested the facility DADM to update LIC 500 (Personnel Summary Report) and Guardian roster. DADM stated S1 will be removed from the staff roster and disassociated from Guardian. LPAs requested a copy of the updated LIC 500.

No deficiencies were cited during today’s visit per California Code of Regulations, Title 22.
An exit interview was conducted with DADM Stephanie Valera and a copy of the report was provided.

End of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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