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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201958
Report Date: 08/25/2021
Date Signed: 09/01/2021 09:42:21 AM

Document Has Been Signed on 09/01/2021 09:42 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CATHELEEN RCH-I & II DBA:CATHELEEN RCH IIFACILITY NUMBER:
435201958
ADMINISTRATOR:PHILIP NUNGAFACILITY TYPE:
735
ADDRESS:2513 SHILSHONE CIRCLETELEPHONE:
(408) 294-1296
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Philip NungaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst, Steve Nguyen, conducted an unannounced annual inspection with Administrator Philip Nunga.

LPA toured facility inside and out. LPA observed: Covid signs are present and in conspicuous vantage points, emergency contact for residents are up to date, facility screening protocols were in effect, hand sanitizing station were available throughout facility, medicine cabinet were observed to be locked, paper towers are in use, beds are at least 6 feet apart and physical distancing was observed to be in practice.

No citation was issued at this time.

LPA went over report findings with Administrator for review and a copy was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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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