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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202640
Report Date: 06/29/2021
Date Signed: 06/30/2021 02:57:25 PM

Document Has Been Signed on 06/30/2021 02:57 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CJCP RCFEFACILITY NUMBER:
435202640
ADMINISTRATOR:GONZAGA, MARITESFACILITY TYPE:
740
ADDRESS:678 HIGH GLEN DRTELEPHONE:
(408) 770-9453
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 6DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Anelia GalinatoTIME COMPLETED:
02:35 PM
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Licensing Program Analyst, Steve Nguyen and Licensing Program Manager, Jackie Jin, conducted an unannounced annual inspection with Administrator Marites Gonzaga.

LPA toured facility inside and out. Observed covid signs are present and in conspicuous vantage points. Emergency contact for residents were up to date. Facility screening protocols were in effect. Hand sanitizing station are available throughout facility. Medicine cabinet were observed to be locked. Paper towers are in use. Beds are at least 6 feet apart and physical distancing was observed to be in practice.

No citation was issued at this time.

LPA went over report findings with Administrator for review and a copy was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
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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