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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201549
Report Date: 02/26/2025
Date Signed: 02/26/2025 02:54:02 PM

Document Has Been Signed on 02/26/2025 02:54 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:CORKTREE HOUSEFACILITY NUMBER:
435201549
ADMINISTRATOR/
DIRECTOR:		CAYABYAB, PERLAFACILITY TYPE:
735
ADDRESS:2170 CORKTREE LANETELEPHONE:
(408) 499-3708
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 6DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Perla Cayabyab Administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with, Perla Cayabyab Administrator. LPA announced the purpose of the visit. LPA observed 2 staff and 1 resident 5 of 6 went to day program.

During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies.

LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature measured with thermometer at 37 degrees F, and freezer at 0 degrees F. During tour LPA observed activity area for residents and an outside sitting area.

LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. ADM tested the smoke detectors the smoke detector to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 110-112 degrees F.

LPA toured the outside area and found the exits to be clear of obstructions. During tour LPA observed activity area for residents and an outside sitting area. LPA observed all windows had screens. LPA observed fire extinguisher was last serviced on 02/20/25. LPA reviewed Fire and Earthquake log was last disaster drill was conducted on 01/07/25.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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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: CORKTREE HOUSE
FACILITY NUMBER: 435201549
VISIT DATE: 02/26/2025
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LPA reviewed 3 resident records. ADM reviewed 2 resident Centrally Stored Medication Record 1 resident does not take any mediction and P & I. LPA reviewed 3 staff records LPA attempted to interview resident who was non verbal rest of residents were at day program

No deficiency were cited as per California Code of Regulations Title 22. This report was reviewed with Perla Cayabyab Administrator and a copy of report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC809 (FAS) - (06/04)
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