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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202631
Report Date: 03/05/2025
Date Signed: 03/05/2025 12:07:51 PM

Document Has Been Signed on 03/05/2025 12:07 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:MINA'S ELDERLY CARE HOME 4FACILITY NUMBER:
435202631
ADMINISTRATOR/
DIRECTOR:
GIMENO, MICHAELFACILITY TYPE:
740
ADDRESS:215 CASTILLON WAYTELEPHONE:
(408) 622-8257
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Mina Abbasvand and Michael GimenoTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Santino Fortes conducted an unannounced annual inspection, and met with Administrator (ADM) Michael Gimeno and Licensee Mina Abbasvand. ADM stated facility has 2 staff and 5 clients.

LPA toured the facility inside and out. There were 4 resident rooms 2 shared and 2 single), 1 staff rooms, 1 living room, dining area and Kitchen. LPA observed resident rooms each equipped with a chair, night stand, sufficient lighting and chest of drawers. Room temperature was 72.6* F. Hot water temperature was measured from resident bathroom at 117* F 117* F and kitchen 118* F. LPA observed the first aid kit to be complete. The facility was equipped with smoke and carbon monoxide detectors, that functioned properly when tested. Fire extinguisher were serviced on 2/18/25. The facility conducted a fire drill on 2/17/25. 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 32.9 * 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 observed to be storing yard and home repair supplies.

LPA observed Facility License and Resident Personal rights were posted. LPA reviewed facility records for 3 staff, 4 clients and observed to be complete. LPA reviewed 4 client’s 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 Licensee. This report was reviewed and a copy was provided to Licensee for signature.
Jackie JinTELEPHONE: (714) 319-3786
Santino FortesTELEPHONE: (818) 378-8120
DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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