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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202423
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:43:12 PM

Document Has Been Signed on 02/02/2023 03:43 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:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mhalou HolmesTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) David Marrufo and Manuel Monter conducted an unannounced Required 1 Year Visit and met with Mhalou Holmes.

During visit, LPAs toured the inside and outside of the facility. The facility had a visitor screening area at the entrance. There was a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. PPE supplies of at least 30 days were observed. There were cleaning supplies observed in the facility in locked storage areas. 3 out of 3 bathrooms had available soap, paper towels, and hand washing signs.

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: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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