435202567-2-23-2026-26-AS-MYAZ-DRKS54-20260223123344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202567
Report Date: 02/23/2026
Date Signed: 02/23/2026 12:33:52 PM

Document Has Been Signed on 02/23/2026 12:33 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: 25	DATE:	02/23/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Joyce Amas		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced case management visit. LPA announced the purpose of the visit and met with Joyce Amas, Designated Administrator (DA). on 02/19/26 the department received a incident report regarding a Resident (R1) who had left the facility unattended and had not returned t0 the facility. DA contacted local law enforcement and filed a missing persons report. R1 frequently leaves the facility unattended and returns. R1 frequently will have depression but at the time of R1 leaving did not show any signs of depression. R1 physicians report does not state if R1 can or can not leave unattended, DA stated this was an oversight. DA stated she will get a new physicians report when resident returns. DA stated that on 02/23/26 local law enforcement called at 9:34 AM to inform DA that R1 was contacted on 02/21/26 and stated R1 was ok. Local law enforcement offered R1 a ride back to facility and he/she stated no. Local law enforcement stated the missing persons case was closed since they made contact with R1. As of 02/23/26 R1 has not returned to facility. On 02/17/26 the department received an incident report for an incident that occurred on 02/15/26 regarding Resident R2 missing and had not returned to faiclity. DA stated she had filed a missing persons report. R2s physicians report states he/she is able to leave unattended. R2 did not show any signs of depression and or suicidal ideation. On 02/17/26 R2s family visited the facility and stated local law enforcement had contacted him/her and stated that R2 had passed away and it was ruled a suicide. R2s family member was distraught and unable to provide any more details as to where resident was found or details regarding suicide. DA stated she did not observe R2 to have any signs of depression and when she last saw him on Friday R2 was eager to see her on monday because she was going to buy him cigarettes. DA stated per log book R2 was observed smoking in front of the house and was instructed to smoke in the backyard. Page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
	VISIT DATE: 02/23/2026

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DA stated R2 did not want to go in backyard and walked away from facility sand was not seen after that.

R2s family collected his/her belongings and stated he/she was going to be cremated.

Designated Administrator stated 2 staff were working at the facility on Sunday when R2 was last seen.

LPA reviewed R1 and R2's file and interviewed Designated Administrator.

No deficiencies cited during today's visit. This report was reviewed with designated Administrator Joyce Amas and a copy of the signed report was provided.

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC809 (FAS) - (06/04)

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