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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202716
Report Date: 08/20/2021
Date Signed: 08/20/2021 11:26:05 AM

Document Has Been Signed on 08/20/2021 11:26 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ACHIEVE ADULT DAY PROGRAMFACILITY NUMBER:
435202716
ADMINISTRATOR:RICHARDS, SHIRLEYFACILITY TYPE:
775
ADDRESS:3930 MONTEREY ROADTELEPHONE:
(408) 821-2477
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 105CENSUS: 0DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Shirley RichardsTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Shirley Richards.

During visit, LPA Marrufo toured the facility. LPA Marrufo toured the kitchen area, office area, activity rooms, hallways, and bathrooms. The facility is not currently under operation and does not have any admitted clients. LPA observed PPE supplies and COVID-19 related posters in the facility.

No deficiencies cited as per California Code of Regulations Title 22.

This report was reviewed with Administrator Shirley Richards and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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