435202171-5-8-2026-26-AS-MPAA-DTW9AD-20260508231147

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202171
Report Date: 04/28/2026
Date Signed: 05/08/2026 11:13:25 PM

Document Has Been Signed on 05/08/2026 11:13 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:	TERRA COTTA HOME		FACILITY NUMBER:	435202171
ADMINISTRATOR/ DIRECTOR:	ANGELINA DOOLABH		FACILITY TYPE:	735
ADDRESS:	3233 TERRA COTTA DR.		TELEPHONE:	(408) 270-7440
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY: 6		CENSUS: 5	DATE:	04/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	Manharlal Doolabh		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual required inspection and met with licensee/administrator (LIC/ADM) Manharlal Doolabh and stated the purpose of the visit. Administrator Angelina Doolabh was not present at the time of the visit due to prior commitment. The facility is licensed to serve six (6) adults developmentally challenged (level 4i/level 6) adults ages 18-59 years. 2 out of 6 maybe non-ambulatory. LPA observed 5 residents who arrived at the facility from the day program and 4 staff at the facility. LPA inspected the facility inside and outside, including common areas, resident rooms, kitchen, bathrooms, driveway, and outdoor spaces and storage areas. Based on observation, the facility has a fenced in swimming pool, that is not being used by the resident or staff. The pool is maintained and the gate going to the pool has padlocks. LPA inspected the living area and dining area, and observed no tripping hazard and was kept organized and sanitary. The walkways leading to the emergency exit is not obstructed. The laundry area is near the staff rooms, and laundry appliances were functional. Cleaning supplies were secured and hallways were clear and well-lit .Indoor temperature was within acceptable range of 70°F. page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

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: TERRA COTTA HOME	FACILITY NUMBER: 435202171
	VISIT DATE: 04/28/2026

NARRATIVE

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The kitchen is observed to be sanitary and organized; knives were locked and not accessible to residents without supervision. Food supply met requirements (2 days perishable, 7 days non-perishable). Kitchen water temperature measured at 128.3°F. A warning sign was observed stating that the tap is delivering hot water over 125°F. Medications are locked and inaccessible to residents. Facility has first aid kit that is readily available when needed.

Facility is a 6 bedroom and 2 bathroom home. LPA inspected 3 resident bedroom and shower and bathroom located at the hallway. The 4 out of 4 residents room were organized and sanitary, with sufficient storage for resident's personal belongings. 3 out of 5 residents does not share a bedroom and 2 out of 5 residents share a bedroom. Two bedrooms are designated for the live-in staff. Bathroom #1 is designated for the resident and Bathroom # 2 is designated for staff. The hot water temperature was measured in the bathroom and the water measured at 119.4 to 124.3°F. A warning sign was observed that the tap may deliver hot water over 125°F.

A technical assistance was provided to LIC/ADM to monitor the hot water temperature not to exceed 125°F. LIC/ADM will have a professional check the water system and regulate the hot water temperature.

LPA reviewed 5 resident files and 3 staff records, including medication logs, admission agreements, care plans, personal and incidentals, health screenings, and staff training. All staff have required clearances and certifications including but not limited to 1st Aid/CPR certification, 35 hours of direct support staff training, continuing education, medication and food safety training. The residents record are complete and updated.

The facility conducts fire and earthquake drills monthly for each shift. Last drill practice training was administered on 04/21/2026, the facility is equipped with wall pull fire alarm system and fire extinguisher were inspected on 06/10/2025. Fire, smoke, and carbon monoxide alarms were operational.

No deficiencies were cited during today's visit based on Title 22 of the California Code of Regulations (CCR). An exit interview was conducted with Licensee/Administrator Manharlal Doolabh, and 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: 04/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

LIC809 (FAS) - (06/04)

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