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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202423
Report Date: 02/04/2022
Date Signed: 02/04/2022 11:32:54 AM

Document Has Been Signed on 02/04/2022 11:32 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
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:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Teresa SaltingTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Teresa Salting. LPA Marrufo also spoke with Licensee Merle Laurel on the telephone during the visit.

During visit, LPA Marrufo observed a visitor entrance at the kitchen area with a visitor screening station that had a screening form and a thermometer. LPA Marrufo observed the kitchen had a perishable food supply of at least three days and a non-perishable food supply of at least seven days. LPA Marrufo observed the PPE supplies to contain gloves, gowns, and masks.

LPA Marrufo toured the facility inside and out and observed the exits to be cleared of obstructions.

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

This report was reviewed with Teresa Salting and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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