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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202574
Report Date: 02/04/2021
Date Signed: 02/04/2021 05:00:51 PM

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:CAHALAN VILLAFACILITY NUMBER:
435202574
ADMINISTRATOR:BENITEZ, MICHELLEFACILITY TYPE:
740
ADDRESS:5903 CAHALAN AVENUETELEPHONE:
(408) 578-8068
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 5DATE:
02/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:59 PM
MET WITH:Michelle BenitezTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an unannounced Case Management tele-visit today and met with Administrator Michelle Benitez. A facility visit was suspended due to COVID-19 restrictions.

At 3:59 PM, LPA conducted a video tour of the facility and met with residents. LPA observed residents in their bedrooms. 4 out of 5 residents were awake and stated they are doing well, staff is available to assist them and they have no complaints. Beds were observed in good repair with bed linens and pillows.

LPA discussed the licensee initiated forfeiture of facility license #435202574 which will be processed immediately. This location is currently licensed as St. Therese Elderly Care Facility #435202787 who will retain current residents. Residents and their responsible parties have been informed of change of licensee. Administrator has been advised that new Admissions Agreements shall be completed under the new facility license.

Exit interview conducted with Administrator. A copy of this report provided to Administrator via email for signature.



SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021
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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