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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202567
Report Date: 11/16/2022
Date Signed: 11/16/2022 11:35:28 AM

Document Has Been Signed on 11/16/2022 11:35 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: 32DATE:
11/16/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Prince-Stanley AmasTIME COMPLETED:
11:30 AM
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A Noncompliance meeting was conducted virtually today via Teams Meeting. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Sarah Yip, Licensing Program Analyst David Marrufo, and facility Administrator Prince-Stanley Amas.

The purpose of the noncompliance meeting was to discuss the serious violation at the facility on 02/22/2020 which resulted in violations under personal rights, administrator qualifications, false claims and emergency intervention prohibition. Substantiated complaint findings were delivered on 11/10/2022 and deficiencies were cited for violations of Title 22 California Code of Regulations.

Facility representatives were informed during non-compliance meeting that additional administrative action may be taken pending legal review for the use of manual restraint on resident. Noncompliance Conference Summary LIC 9111 and a compliance plan were established during the meeting.

Report was reviewed with Administrator Prince-Stanley Amas. A copy of this report, LIC 9111, and link resources https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers
were provided to Licensee for signature via email.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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