<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201710
Report Date: 10/05/2022
Date Signed: 10/05/2022 11:59:12 AM

Document Has Been Signed on 10/05/2022 11:59 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:KERN A.R.F.FACILITY NUMBER:
435201710
ADMINISTRATOR:SASHI KUMARFACILITY TYPE:
735
ADDRESS:2785 KERN AVE.TELEPHONE:
(408) 281-7057
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 4DATE:
10/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ernie ManaoisTIME 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) David Marrufo conducted an unannounced Required 1 Year visit and met with Ernie Manaois.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed there to be a visitor screening area. The facility had a 2 day supply of perishable food and a 7 day supply of non-perishable food. The facility had a PPE supply of 30 days. The facility bathroom had available soap, paper towels, and a hand washing poster. The outdoor area was toured and the backyard ramp was observed to have loose floor boards.

An advisory notice was issued. See LIC9102 for more information.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Ernie Manaois and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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 1