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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202092
Report Date: 11/21/2022
Date Signed: 11/21/2022 03:10:35 PM

Document Has Been Signed on 11/21/2022 03:10 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:THELMA'S HOMEFACILITY NUMBER:
435202092
ADMINISTRATOR:THELMA B. RUIZFACILITY TYPE:
735
ADDRESS:1164 CAMANO CT.TELEPHONE:
(408) 292-6631
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Elenita GanoTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Elenita Gano.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed there to be a visitor screening area at the entrance. LPA Marrufo observed a perishable food supply of 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a PPE supply of at least 30 days. LPA Marrufo observed the facility bathroom to have available soap, paper towels, and hand washing signs. LPA Marrufo toured the outdoor area and observed the exit to be clear of obstructions.

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

This report was reviewed with Elenita Gano and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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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