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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202728
Report Date: 10/03/2022
Date Signed: 10/03/2022 11:57:35 AM

Document Has Been Signed on 10/03/2022 11:57 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SYCAMORE HOMEFACILITY NUMBER:
435202728
ADMINISTRATOR:NOEL HUANTEFACILITY TYPE:
737
ADDRESS:15160 SYCAMORE AVETELEPHONE:
(408) 915-5970
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 4CENSUS: 3DATE:
10/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Noel HuanteTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Noel Huante.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed a visitor screening area at the entrance. LPA Marrufo observed a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a PPE supply of at least 30 days. LPA Marrufo observed 3 out of 3 resident hallway bathrooms had available soap and paper towels. The outdoor exits were observed to be clear of obstructions.

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

This report was reviewed with Administrator Noel Huante and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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