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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202567
Report Date: 09/09/2021
Date Signed: 09/09/2021 04:08:20 PM

Document Has Been Signed on 09/09/2021 04:08 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: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: 30DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Prince-Stanley AmasTIME COMPLETED:
04:15 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 inside and outside of the facility. LPA observed a visitor screening area at the facility entrance. LPA toured the resident hallways and bathrooms. LPA observed COVID-19 related signs in the hallway and bathrooms.

LPA observed 30-days worth of PPEs.

LPA Marrufo toured the kitchen and food storage area and found there to be a 7 day supply of perishable foods and a 3 day supply of non-perishable foods.

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

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