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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202589
Report Date: 02/25/2025
Date Signed: 02/25/2025 04:40:22 PM

Document Has Been Signed on 02/25/2025 04:40 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:MUNA'S CARE HOME IIIFACILITY NUMBER:
435202589
ADMINISTRATOR/
DIRECTOR:
SEDIGH, TAYEBEHFACILITY TYPE:
735
ADDRESS:275 MORAGA WAYTELEPHONE:
(408) 300-1227
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6CENSUS: 5DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Muna Qaddura TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analysts (LPA) Santino Fortes conducted an unannounced annual inspection, and met with Administrator (ADM) Muna Qaddura. ADM stated facility has 3 staff and 5 clients.

LPA toured the facility inside and out. There were 4 resident rooms (shared), 1 staff rooms, 1 living room, and Kitchen. LPA observed resident rooms each equipped with a chair, night stand, sufficient lighting and chest of drawers. Room temperature was at 75* F. Hot water temperature was measured from resident bathroom at 119* F, 119* F, Kitchen 119* F. LPA observed the first aid kit to be complete. The facility was equipped with smoke and carbon monoxide detectors, and all functioned properly when tested. Fire extinguishers were serviced on 3/6/2024. The facility conducted a fire drill on 1/2/25. Restrooms observed to have non skid flooring. LPAs observed perishable food supply of at least two days and non-perishable food supply of at least seven days. Refrigerator temperature was observed at 44.6* F and Freezer temperature was 0*. LPA observed medication storage, knives storage, and cleaning product storage locked and inaccessible to clients in care.

The front and back yards of the facility were inspected. Outdoor exits and walkways were unobstructed. Facility has 1 storage shed that was used to store garden tools and home repair items

LPA observed Facility License and Resident Personal rights were posted. LPA reviewed facility records for 3 staff, 5 clients and observed to be complete. LPA reviewed 5 clients medications, centrally stored medication records and observed to be complete.

No deficiencies were cited during today's visit as per California Code of Regulations Title 22. Exit interview was conducted with ADM. This report was reviewed and a copy was provided to ADM for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Santino Fortes
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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