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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202631
Report Date: 03/05/2024
Date Signed: 03/05/2024 04:32:11 PM


Document Has Been Signed on 03/05/2024 04:32 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:GIMENO, MICHAELFACILITY TYPE:
740
ADDRESS:215 CASTILLON WAYTELEPHONE:
(408) 622-8257
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY:6CENSUS: 6DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mina AbbasvandTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Mina Abbasvand.

During visit, LPA Marrufo toured the facility inside and out. The facility kitchen area had a perishable food supply of at least two days and a non-perishable food supply of at least 7 days. The first aid kit was complete and there were locked storage areas for cleaning supplies, sharp objects, and medications.

LPA Marrufo toured 5 out of 5 resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as working lights. The smoke detectors in each resident room and in the hallway and living room areas functioned properly when tested. The carbon monoxide detector functioned properly when tested.

LPA Marrufo toured the outside area and 2 out of 2 outdoor exits were clear of obstructions.

LPA Marrufo reviewed resident and staff records and found them to be complete.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Mina Abbasvand and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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