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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202567
Report Date: 08/18/2022
Date Signed: 08/31/2022 09:51:10 AM

Document Has Been Signed on 08/31/2022 09:51 AM - 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: 30DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Prince-Stanley AmasTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Prince-Stanley Amas.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed there to be a visitor screening area. LPA Marrufo observed there to be a 30-day supply of PPEs. LPA Marrufo observed there to be a two day supply of perishable foods and a 7 day supply of non-perishable foods. LPA Marrufo observed the resident restrooms. LPA Marrufo observed the outdoor area and found the exits to be clear of obstructions.

No deficiencies were cited at this time 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: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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