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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202424
Report Date: 07/08/2022
Date Signed: 07/08/2022 01:55:08 PM


Document Has Been Signed on 07/08/2022 01:55 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:CASA LAURELFACILITY NUMBER:
435202424
ADMINISTRATOR:SOL SAMONTEFACILITY TYPE:
740
ADDRESS:680 NORTH 18TH ST.TELEPHONE:
(408) 287-4541
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:6CENSUS: 5DATE:
07/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Manuel and Illuminada YapTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Manuel and Illuminada Yap.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed a visitor screening area with a symptom screening form, thermometer, hand sanitizer, and PPEs. The facility has a 30-day supply of PPEs. COVID-19 related posters were observed in the facility hallway and living room. LPA Marrufo toured the faciity bathroom and observed there to be available soap and a hand washing sign. LPA Marrufo observed the facility had a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days.

LPA Marrufo toured the outside of the facility and observed the facility exits to be clear of obstructions.

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

This report was reviewed with Manuel and Illuminada Yap and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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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