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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202472
Report Date: 04/26/2022
Date Signed: 04/26/2022 04:03:52 PM

Document Has Been Signed on 04/26/2022 04:03 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:LUXURY VILAFACILITY NUMBER:
435202472
ADMINISTRATOR:MR. CYRIL INNEHFACILITY TYPE:
735
ADDRESS:27/41 SOUTH 11TH STREETTELEPHONE:
(408) 903-3151
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 39CENSUS: 7DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Cyril InnehTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Cyril Inneh.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo toured the kitchen area 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 there to be a PPE supply of at least 30 days. LPA Marrufo observed there to be a visitor screening area. The facility hallways had COVID-19 related signs. 3 out of 3 resident bathrooms had available soap and paper towels as well as hand washing signs.

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

This report was reviewed with Administrator Cyril Inneh and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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