<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202423
Report Date: 01/30/2024
Date Signed: 01/30/2024 04:49:31 PM


Document Has Been Signed on 01/30/2024 04:49 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: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: 14DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Mhalou HolmesTIME 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) David Marrufo conducted an unannounced Required 1 Year visit and met with Mhalou Holmes.

During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and the other food storage areas and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least 7 days. LPA Marrufo observed locked storage areas for sharps and cleaning supplies. The facility smoke detectors functioned properly when tested.

LPA Marrufo toured 3 out of 3 bathrooms and observed the bathrooms to have available soap and paper towels as well as available lighting.

The outside area exit was clear of obstructions.

Due to time constraints, the annual inspection will need to be continued at a further date.

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 this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1