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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202117
Report Date: 02/19/2025
Date Signed: 02/19/2025 11:39:55 AM

Document Has Been Signed on 02/19/2025 11:39 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:SILVER STAR RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202117
ADMINISTRATOR/
DIRECTOR:		FE.O.PUNZALANFACILITY TYPE:
735
ADDRESS:5130 SAN FELIPE RD.TELEPHONE:
(408) 270-6005
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 6CENSUS: 4DATE:
02/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Mark Arvin Agustin & Nilo AmbaganTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 2/19/2025 at 8:45 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management visit regarding an incident report that was received by the department on 2/18/2025 involving a resident. LPA met with staff and designated administrator (S1/DADM) Mark Arvin Agustin and staff Nilo Ambagan (S2) LPA stated the purpose of the visit.

LPA observed no resident present at the time of the visit and S1/DADM stated all residents were currently attending the day program. LPA observed that the facility was sanitary, organized, no debris or obstruction on the walkways and hallways. LPA conducted a file review and requested copies of the resident's file and staff file including but not limited to, staff certificate and training, designation of facility responsibility, resident roster, physician's report, appraisal needs and services plan, medication list, Individual Program Plan (IPP), medical assessments and progress notes.

No deficiency cited during today's visit. Due to insufficient information this case management will remain open until further investigation.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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