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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202117
Report Date: 11/07/2025
Date Signed: 11/10/2025 07:18:17 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/10/2025 07:18 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:
11/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Mark Arvin Agustin - Designated AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza a conducted an unannounced required 1 year inspection visit. LPA was greeted by two staff (S1& S2) and called Designated Administrator Mark Arvin Agustin. On 10/8/25, LIC/ADM sent a notification to LPA and assigned Mark Arvin Agustin to be the designated administrator in his/her absence while LIC/ADM is out. LPA met with designated administrator (DADM) and stated the purpose of the visit.

The facility is licensed to serve 18 to 59 years old who are developmentally challenged. All may be non-ambulatory. A detached ADU at the rear of the facility is approved to be occupied by staff.

At 12:30 p.m. LPA toured the facility inside and outside with including but not limited to the kitchen, bathroom, dining room, living room, 3 residents rooms, 2 Staff room, activity area, laundry area, pantry, backyard and exterior walkways. LPA observed no obstruction on the walkways both inside and outside. The overall condition of the facility is organized and in good repair. Ramp for non-ambulatory are clear from obstruction and in good repair.

LPA observed the washer and dryer area was in good working condition, chemicals are separated from the food pantry. LPA observed that 3 Out of 3 resident bedroom have sufficient lighting, sufficient storage for resident's personal belongings. 2 Out 2 bathroom used by residents have grab bars and anti-skid floor. The facility has a dining area and a living area that are free from debris and organized. 4 Out of 4 residents arrived from the day program, accompanied by 3 staff.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 435202117
VISIT DATE: 11/07/2025
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LPA Partoza measured the hot water temperature for 2 out of 2 bathrooms and kitchen. The water temperature was measured with a digital thermometer at 105.7 degrees F. The facility room temperature is at 68 degree F. LPA observed 1 refrigerator, freezer combination located in the kitchen area. The refrigerator temperature measured at 38 degree F and freezer is at 0 degree F.

The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. Under the sink cabinet is used to store some cleaning supplies and kept locked.

LPA tested the carbon monoxide detectors and smoke alarms and verified that it is in good working condition. The facility is equipped with a fire extinguisher that was last tested on 03/5/2025 Emergency preparedness training drill was done on 09/14/25, earthquake and fire drill are administered monthly last drill practice was done on 10/20/25 and 10/21/25. The facility has audible alarms for all exit doors.

LPA reviewed 4 out of 4 resident files and observed that residents files were complete and updated including but not limited to Centrally Stored Medication and Destruction Record (CSMDR), Personal and Incidental (P&I) allowance, appraisal needs and services plan, medical assessment, personal rights and individual program plan.

LPA reviewed 3 staff record, and observed that the staff records were complete and updated including but not limited, to staff training required by the San Andreas Regional Center (SARC) for direct support professionals (DSP), 1st Aid/CPR certificates are current, staff have criminal background clearance, health screening with negative TB test results,, mandated reporter (SOC 341A) and continuing education.

No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Designated Administrator Mark Arvin Agustin. A copy of the report was provided.

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end of report
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC809 (FAS) - (06/04)
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