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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202728
Report Date: 04/23/2024
Date Signed: 04/28/2024 02:02:26 AM

Document Has Been Signed on 04/28/2024 02:02 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/
DIRECTOR:
NOEL HUANTEFACILITY TYPE:
737
ADDRESS:15160 SYCAMORE AVETELEPHONE:
(408) 915-5970
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 4CENSUS: 4DATE:
04/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Debrah Vasquez - Lead StaffTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 4/23/2024 Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management deficiencies visit. LPA stated the purpose of the visit and met with Debrah Vasquez lead staff (LS). Noel Huante administrator was not present at the facility at the time of the visit.

LPA with LS toured the facility including but not limited to the living room, dining room, kitchen, resident's room, garage and bathrooms and the exterior perimeter.

Current census is 4 resident and 1 out of 4 is out attending day program and 6 staff are present during the visit. LPA observed that floors were repaired and all residents and staff are back to their normal routine. Window shade of one of the resident was broken, linen lower cabinet door and laundry room lower cabinet doors were broken. LS stated that the broken window shades and cabinet doors was very recent and are scheduled to be repaired.

LPA observed that the exterior fence has a broken plank a double door gate with padlock and a single gate to the right without a padlock that leads to the fenced in water supply and an electrical panel for the pump. LS stated that repairs are scheduled to be fixed within a week or two. The padlock will be placed on the latch mechanism of gate that holds the water supply and pump as a preventative measure.

LPA reminded LS about the importance that of reporting that any changes in the plan of operation which affect the services to clients shall be subject to licensing agency approval and shall be reported as specified in Title 22, Division 6 Chapter 1 Article 06. Continuing Requirements 80061 reporting requirements.

No deficiency was cited during today's visit. An exit interview was conducted with Lead Staff Debrah Vasquez and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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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