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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202728
Report Date: 05/06/2024
Date Signed: 05/28/2024 02:54:01 PM

Document Has Been Signed on 05/28/2024 02:54 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: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:
05/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:David Sindhu and Jovana McGrawTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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On 5/6/2024, LIcensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management visit and stated the purpose of the visit. LPA met with David Sandhu - Director of Operations (DO) and Jovana McGraw - Behavioral Specialist (BS).

On 4/23/2024, LPA conducted a case management visit and observed the following:
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. 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

During today's visit, LPA observed the following, 1 worker, 7 staff (S1 to S7), 4 out of 7 staff are with the resident, 3 out of 4 residents were observed to be present in the facility. 1 out of 4 resident was out attending day program. 1 out of 4 resident was in the living room, 2 out of 4 were inside their room.

LPA toured the facility and observed broken blinds inside one of the resident's room, laundry room lower cabinet, and lower cabinet of the linen closet both needed repair. S1 stated, the cabinet doors were measured today. DO stated that the landlord have been notified and informed of the need to repair the cabinets. LPA observed that the walls are being repaired. DO stated the missing plank/s on the fence will be repaired within the next two weeks. 1 out of 4 resident room had a broken window blinds, DO stated the blinds were measured today and scheduled to be replaced.
No deficiencies were cited during today's visit. This case management will stay open until the next visit. An exit interview was conducted with the Director of Operations (DO) David Sandhu and Behavior Specialist Jovana McGraw. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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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