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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202798
Report Date: 07/21/2023
Date Signed: 07/21/2023 02:54:32 PM

Document Has Been Signed on 07/21/2023 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:COPELAND HOUSEFACILITY NUMBER:
435202798
ADMINISTRATOR:CANLAS, AVELINO R JR.FACILITY TYPE:
735
ADDRESS:512 CENTURY OAKS WAYTELEPHONE:
(408) 823-7168
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 6DATE:
07/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jun AvelinoTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) David Marrufo and Deputy Director Kevin Gaines conducted an unannounced Required - 1 Year visit and met with Administrator Jun Canlas.

During visit, LPA toured the facility inside and out. The facility kitchen was observed to have locked cabinets for medications, cutlery, and cleaning supplies. The food supplies in the kitchen, pantry, and garage were observed and the facility was observed to have a perishable food supply of at least two days and a non-perishable food supply of at least 7 days. The facility was observed to have two fire extinguishers with service tags dated January 2023.

The facility smoke detector system was tested and found to be functional. The carbon monoxide detector was tested and found to be functional. LPA toured 2 out of 2 facility restrooms and observed the restrooms to have available soap and paper towels. The showers had grab bars, shower chairs, and non-slip mats. The bathroom sink water temperatures measured at 106 F and 107 F.

3 out of 3 resident bedrooms were observed. Each bedroom had available bedding, clothing storage, and functioning lighting. The outdoor area was observed and the exit was found to be clear of obstructions.

The Personal and Incidental Money Logs were reviewed for 6 out of 6 residents and found to be complete. LPA reviewed medications and the Centrally Stored Medication Logs for 6 out of 6 residents and the logs were found to be complete.

LPA reviewed 6 out of 6 resident records and the Safeguard of Property and Valuables Forms for 6 out of 6 residents were found to be missing signatures from residents/resident representatives and licensee. An Advisory Note - Technical Violation was issued. See LIC9102 for more information.
See LIC809-C for more information. Page 1 of 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: COPELAND HOUSE
FACILITY NUMBER: 435202798
VISIT DATE: 07/21/2023
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LPA reviewed 6 staff records and 6 out of 6 staff records were found to be complete.

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

This report was reviewed with Administrator Jun Canlas and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
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