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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202423
Report Date: 10/01/2021
Date Signed: 10/01/2021 02:59:37 PM

Document Has Been Signed on 10/01/2021 02:59 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LAUREL HAVENFACILITY NUMBER:
435202423
ADMINISTRATOR:TERESITA SAMONTEFACILITY TYPE:
740
ADDRESS:1157 SOUTH SIXTH ST.TELEPHONE:
(408) 287-5074
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 15CENSUS: 11DATE:
10/01/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mhalou HolmesTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Collateral visit and met with Mhalou Holmes. The purpose of the visit was to request personal documents from resident R1.

During visit, LPA Marrufo met with resident R1 and R1 refused to provide the documents. LPA Marrufo did not obtain any documents during visit.


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

This report was reviewed with Mhalou Holmes and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
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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