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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202517
Report Date: 09/14/2022
Date Signed: 09/14/2022 12:10:02 PM

Document Has Been Signed on 09/14/2022 12:10 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: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: 8DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Carrie AquinoTIME COMPLETED:
12:15 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 inside and outside of the facility. LPA Marrufo observed the entrance to have a visitor screening area. A PPE supply of at least 30 days was observed. LPA Marrufo observed cleaning supplies at the facility. LPA Marrufo observed 3 out of 3 resident 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 Carrie Aquino and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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