<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202617
Report Date: 12/21/2023
Date Signed: 12/21/2023 01:30:55 PM

Document Has Been Signed on 12/21/2023 01:30 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
Lookup Error,
, CA
FACILITY NAME:MOUNT PLEASANT CARE HOMEFACILITY NUMBER:
435202617
ADMINISTRATOR:DUMANTAY, MADONNA O.FACILITY TYPE:
735
ADDRESS:3280 COLDWATERDRTELEPHONE:
(408) 238-1662
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Madonna Dumantay
Portia Oviso		TIME COMPLETED:
01:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/21/23, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA Medina introduced self, stated purpose of visit, and allowed entrance by Madonna Dumantay, Administrator and Portia Oviso House Manager.

Currently, 6 residents are in placement. Three residents were present and 3 were at day program at time of inspection. Residents attend day program Monday through Friday 8:00 am - 3:30pm.

Facility tour conducted with Administrator and House Manager. Facility observed to be well lit, clean and odor free. All common areas have adequate seating available. Resident bedrooms toured, all bedrooms observed to have required furnishings and exits to exterior of facility. Bathrooms toured, showers observed to have non-slid bases and shower chairs available. Water temperature during facility inspection measured at 105 degrees F. Kitchen toured, all sharps observed to be locked and secured in lock box. Facility observed to have a 2-day supply of perishable and 7-day of non-perishable available. Medication observed to be locked and secured in medication cabinet. Medication observed to be administered as ordered. Smoke detectors and carbon monoxide detector observed operational during inspection. Fire extinguisher present with a purchase date of 4/18/23. Chemicals observed to be locked in garage as well as locked cabinet in side yard. Staff and resident files reviewed.

SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: MOUNT PLEASANT CARE HOME
FACILITY NUMBER: 435202617
VISIT DATE: 12/21/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Outside of facility toured. All exits open free of obstruction. Perimeter of back yard is secured with a fence and free of obstruction. Storage shed in the back yard is locked, secured, and inaccessible to residents.

Administrator to submit the following updated documents to the local Regional Office no later than 12/29/23:
1) LIC 308
2) LIC 500
3) LIC 610D
4) Copy of Surety Bond
5) Copy of Lease of Agreement
6) Copy of Administrator Certificate

Exit interview Conducted. No deficiencies cited during inspection.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2