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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202517
Report Date: 09/22/2021
Date Signed: 09/22/2021 12:18:32 PM

Document Has Been Signed on 09/22/2021 12:18 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:NATIONAL PSYCHIATRIC CARE AND REHABILITATION SERVFACILITY NUMBER:
435202517
ADMINISTRATOR:ANTHONY WILLIAMSFACILITY TYPE:
772
ADDRESS:650 SOUTH 5TH STREETTELEPHONE:
(408) 568-1174
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 15CENSUS: 14DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Carrie AquinoTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Carrie Aquino.

During visit, LPA Marrufo toured the interior and exterior of the facility. LPA observed there to be a central entry point with COVID-19 symptom screening for visitors. LPA observed there to be a PPE supply of at least 30 days and a PPE cart with PPE donning and doffing instructions. LPA toured 4 out of 4 hallway bathrooms and observed there to be COVID-19 related posters and hand washing instructions as well as available soap and paper towels. LPA toured the facility kitchen and dinning areas as well as the facility hallways and observed there to be COVID-19 related posters throughout the facility. LPA toured the exterior exits and found them to be clear of obstructions.

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

This report was reviewed with Carrie Aquino and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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