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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201958
Report Date: 01/30/2025
Date Signed: 01/30/2025 04:00:46 PM

Document Has Been Signed on 01/30/2025 04:00 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:CATHELEEN RCH-I & II DBA:CATHELEEN RCH IIFACILITY NUMBER:
435201958
ADMINISTRATOR/
DIRECTOR:		JULIUS ERVIN JAVIERFACILITY TYPE:
735
ADDRESS:2513 SHILSHONE CIRCLETELEPHONE:
(408) 294-1296
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
01/30/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Lead Staff, Shierre MedulaTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management - Incident visit regarding a self-reported Incident Report for an incident which occurred on 1/29/2025. LPA met with Lead Staff, Shierre Medula and stated the purpose of the visit.

On 1/30/2025, the Department received an Incident Report stating on 1/29/2025 regarding alleged physical abuse by staff (S1) towards resident (R1).

During today' visit, LPA Rai interviewed 1 staff and 3 residents.

LPA Rai obtained the following copies of documents such as but not limited to S1's training records, R1's Physician's Report and R1's Appraisal/Needs and Services Plan.

Lead Staff, Shierre will email LPA Rai additional documents such as but not limited to S1's additional training records by Friday, January 31st, 2025.

At this time, LPA Rai determined this case management needs further investigation.

The report was reviewed with Lead Staff, Shierre Medula and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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