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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202567
Report Date: 09/28/2023
Date Signed: 09/28/2023 04:31:01 PM

Document Has Been Signed on 09/28/2023 04:31 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:SUCCESS RCF 1FACILITY NUMBER:
435202567
ADMINISTRATOR:AMAS, PRINCE-STANLEYFACILITY TYPE:
735
ADDRESS:64/68 SOUTH 10TH STREETTELEPHONE:
(408) 293-8166
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 32CENSUS: 29DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Prince-Stanley AmasTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Prince-Stanley Amas.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed food storage areas had a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA Marrufo observed 3 out of 3 carbon monoxide detectors functioned properly when tested and the facility had a smoke detector report for a test that was conducted by a third party on 09/27/2023. The report stated that all smoke alarms functioned properly.

LPA Marrufo observed 17 out of 17 resident bedrooms and observed each bedroom to have functional lights and bedding. LPA Marrufo observed 3 out of 3 resident bathrooms and observed each bathroom had functional lights and available soap and paper towels. LPA Marrufo observed the sink water temperatures to be 118 F. The outdoor exit was observed to be clear of obstructions.

LPA Marrufo reviewed facility records. LPA Marrufo observed 10 resident records and found them to be complete. LPA Marrufo reviewed resident medications, Centrally Stored Medication Logs, Medication Administration Records, and Personal and Incidental Money Logs for 5 residents and found them all to be complete. LPA Marrufo observed staff records and observed staff S1-S3 were missing LIC9052 Employee Rights forms and staff S3 was missing an LIC508 Criminal Records Statement.

An Advisory Note was issued. Please see LIC9102 for more information. No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Administrator Prince-Stanley Amas and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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