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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202492
Report Date: 07/07/2022
Date Signed: 07/07/2022 04:25:11 PM

Document Has Been Signed on 07/07/2022 04:25 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:DYSICO CARE HOME, ARFFACILITY NUMBER:
435202492
ADMINISTRATOR:JOSEPHINE DYSICOFACILITY TYPE:
735
ADDRESS:787 E. SAN CARLOS STREETTELEPHONE:
(408) 286-5364
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 6CENSUS: 6DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Wilma GomezTIME COMPLETED:
04:34 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Wilma Gomez.

During visit, LPA Marrufo toured the inside and outside of the facility. The facility maintains a visitor screening log with symptom screening questions and a thermometer. LPA Marrufo observed a 30-Day supply of PPEs. There was a 2 day supply of perishable foods and a 7 day supply of non-perishable foods. LPA Marrufo toured the facility bathrooms and found them to have available soap and paper towels.

The outdoor area exits were clear of obstructions.

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

This report was reviewed with Wilma Gomez and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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