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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202680
Report Date: 10/17/2022
Date Signed: 10/17/2022 12:20:42 PM

Document Has Been Signed on 10/17/2022 12:20 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:VINCI PARK ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202680
ADMINISTRATOR:MELDA RIPARIP ANTONIOFACILITY TYPE:
735
ADDRESS:5875 HERMA STREETTELEPHONE:
(408) 518-2250
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 4DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Melda Riparip AntonioTIME COMPLETED:
12:21 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Melda Riparip Antonio.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed a visitor screening area at the entrance. There was a 30-Day supply of PPEs, a 2 day supply of perishable foods and a 7 day supply of non-perishable foods. LPA Marrufo observed cleaning supplies to be stored in a locked area. The facility bathroom had available soap, paper towels, and hand washing signs. The outdoor exits were clear of obstructions.

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

This report was reviewed with Melda Riparip Antonio and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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