<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202793
Report Date: 12/16/2024
Date Signed: 12/16/2024 04:58:28 PM

Document Has Been Signed on 12/16/2024 04:58 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:KOEN ARFFACILITY NUMBER:
435202793
ADMINISTRATOR/
DIRECTOR:		KOEN, DEREKFACILITY TYPE:
735
ADDRESS:1620 RAVENS PLACE WAYTELEPHONE:
(646) 423-7601
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
12/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:15 PM
MET WITH:Lead staff Victoria AgnesTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management- Deficiencies visit. LPA met with Lead staff Victoria Agnes. LPA explained the purpose of the visit. During the visit, LPA observed 6 residents and 2 staff.

The purpose of the visit is regarding to deficiencies cited on November 14, 2024 and to verify that the plan of corrections are being followed. The following are the some of the deficiencies cited that are being inspected today which included the following;
1. Buildings and Grounds
2. Fire Clearance

LPA toured the facility garage and observed it being used as a storage space.

LPA spoke with ADM regarding his plan of action regarding what he will use the garage for going forward. ADM stated he will use the garage as a storage space. ADM stated Lead staff Victoria Agnes could sign on his behalf.

No deficiencies cited during today's visit. This report was reviewed with Lead staff Victoria Agnes and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1