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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202567
Report Date:
04/22/2024
Date Signed:
04/22/2024 04:06:23 PM
Document Has Been Signed on
04/22/2024 04:06 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 1
FACILITY NUMBER:
435202567
ADMINISTRATOR/
DIRECTOR:
AMAS, PRINCE-STANLEY
FACILITY TYPE:
735
ADDRESS:
64/68 SOUTH 10TH STREET
TELEPHONE:
(408) 293-8166
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95112
CAPACITY:
32
CENSUS:
29
DATE:
04/22/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:
Joyce Amas
TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Joyce Amas.
The purpose of the visit was to amend a complaint report from 11/01/2023.
No deficiencies were cited at this time as per California Code of Regulations Title 22.
This report was reviewed with Joyce Amas and a copy of the report was provided.
SUPERVISORS NAME
:
Sarah Yip
LICENSING EVALUATOR NAME
:
David Marrufo
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/22/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/22/2024
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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