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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202793
Report Date: 01/16/2025
Date Signed: 01/16/2025 01:38:47 PM

Document Has Been Signed on 01/16/2025 01:38 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:
01/16/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Administrator Catherine KoenTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management- Deficiencies visit. LPA met with Administrator Catherine Koen. LPA explained the purpose of the visit. During the visit, LPA observed 5 residents and 2 staff.

The purpose of the visit is a follow up visit regarding the pending status of the garage wall partition.
LPA toured the facility garage and observed the wall partition.

On January 9, 2025, LPA spoke with fire department, who stated the partition in the garage does not have a permit.

On January 13, 2025, LPA spoke with ADM. ADM confirmed that facility did not get a building permit for the partition wall in the garage.

During todays visit, LPA spoke with ADM via phone call. ADM stated regarding his plan of action regarding the garage partition wall. ADM stated he will remove the garage partition wall and notify LPA once it has been removed.

A Deficiency is being cited during today's visit. This report was reviewed with Administrator Catherine Koen and a copy of the signed report was provided. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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Document Has Been Signed on 01/16/2025 01:38 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/16/2025 at 01:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: KOEN ARF
FACILITY NUMBER: 435202793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2025
Section Cited
CCR
80086(c)

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80086 Alterations to Existing Building or New Facilities (c) Prior to construction or alterations, state or local law requires that all facilities secure a building permit.
This requirement was not met as evidenced by;
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ADM stated he will send a written plan of action addressing the partition wall in the garage. ADM stated he will send this written plan of action to LPA by POC date, January 23, 2025.
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Based on interview and record review, the partition wall in the garage does not have a building permit. ADM stated the facility did not obtain a permit prior to building the partition wall in the garage. This poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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