435200974-3-14-2025-26-AS-MPAA-DERQ5E-20250314115148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200974
Report Date: 03/14/2025
Date Signed: 03/14/2025 11:52:11 AM

Document Has Been Signed on 03/14/2025 11:52 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:	CHURCH RCF		FACILITY NUMBER:	435200974
ADMINISTRATOR/ DIRECTOR:	ZIPAGAN, AZUCENA		FACILITY TYPE:	740
ADDRESS:	1306 CHURCH AVENUE		TELEPHONE:	(408) 686-0751
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Azucena Zipagan Licensee/Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual inspection visit and met with Licensee/Administrator (LIC/ADM) Azucena Zipagan and assistant administrator (AADM) Triponia M. Tuazon. The facility has 6 resident and 4 staff, including LIC/ADM and AADM. All residents are currently out of the facility attending day program at the time of the visit. LPA observed the following are displayed prominently and can be easily seen; facility license, personal rights, administrator certificate and visitor hours posters were observed at the main entrance. LPA toured the exterior and interior of the facility with AADM. LPA inspected living room, kitchen, dinning area, restrooms, laundry room and garage. The facility has 4 resident bedrooms. 3 restrooms, 1 staff room. One of the staff room has been converted to a resident bedroom in June 15, 2024, the room is located at the end of the hallway towards the garage, and has it's own emergency exit door. No significant changes to the wall or layout of the facility. LPA observed medication, knives and toxic materials including but not limited to laundry detergents are in a locked cabinet not easily accessible. Non-skid mats and handle bars were observed in bathrooms. Room temperature was observed at 68 to 76 degree Farenheit (F) and water temperature in the bathroom and kitchen measured from 110 to 120 degree F. Warning signs that water temperature may exceed 120 degree F was prominently displayed. Refrigerator temperature was measured at 35 degree F, freezer temperature was measured at negative 10 degree F. LPA observed 2 days of perishable and 7 days non-perishable food. Continued on LIC 809C page 1 of 2

Romeo Manzano	TELEPHONE: (650) 388-2297
Maria Partoza	TELEPHONE: (669) 308-3994
	DATE: 03/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: CHURCH RCF	FACILITY NUMBER: 435200974
	VISIT DATE: 03/14/2025

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LPA observed the facility is equipped with fire alarm wall system, fire sprinklers, carbon monoxide and smoke detector. The facility is inspected by Northern California Fire Protection Services annually for compliance and maintenance. Smoke alarm and carbon monoxide detector were tested and were found in good working condition. The fire extinguishers complies with the Fire Marshall's requirement. The interior hallways have working night lights.

LPA toured he exterior and interior perimeter, ramps and walkways were free from any obstruction and debris. LPA reviewed 3 residents and 2 staff records. The records were complete and updated for the residents. The staff records were updated.

No deficiencies and citations were issued for today's visit per California Code of Regulations Title 22. An exit interview was conducted with LIC/ADM Azucena Zipagan and signed copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

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