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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202617
Report Date: 03/19/2025
Date Signed: 03/19/2025 11:08:14 AM

Document Has Been Signed on 03/19/2025 11:08 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:MOUNT PLEASANT CARE HOMEFACILITY NUMBER:
435202617
ADMINISTRATOR/
DIRECTOR:		DUMANTAY, MADONNA O.FACILITY TYPE:
735
ADDRESS:3280 COLDWATERDRTELEPHONE:
(408) 238-1662
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Madonna Dumantay AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Madonna Dumantay Administrator. LPA announced the purpose of the visit. LPA observed 3 of 6 residents, and 4 staff. 2 of 6 residents at day program.

During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies.

LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature measured on door of refrigerator at 33 degrees F and freezer at -3 degrees F.

LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. ADM tested smoke detectors and found the smoke detector to function properly when tested. LPA toured 2 resident bathrooms. Bathroom #2 had available soap and paper towels and functioning lights. Bathroom 1 was a half bathroom. The water temperature in the bathroom #2 sink measured with thermometer at 106.7 degrees F.

During tour LPA observed a common area used for residents to watch television and read books and play board games. During tour LPA observed 1 resident playing cards and matching game. 2 of the residents were observed watching television. LPA observed staff cleaning and preparing lunch for residents.

LPA observed first aid kit complete with gauze, scissors and first aid kit guide, and flashlights were also observed

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: MOUNT PLEASANT CARE HOME
FACILITY NUMBER: 435202617
VISIT DATE: 03/19/2025
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LPA toured the outside area and found the exits to be clear of obstructions. LPA observed locked storage shed used for storage and not a living space.

LPA observed fire extinguisher that was purchased on 11/12/24, in the kitchen by the stove. LPA reviewed Fire and Earthquake log. The last disaster drill on 3/3/25.

LPA reviewed resident records for 3 residents and 3 staff records. ADM reviewed P & I and centrally stored medication record.

No deficiency were cited as per California Code of Regulations Title 22. This report was reviewed with Madonna Dumantay, Administrator and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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