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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202798
Report Date: 01/26/2024
Date Signed: 01/26/2024 11:15:01 AM

Document Has Been Signed on 01/26/2024 11:15 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: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:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Red DionioTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Red Dionio, Assistant Administrator. During visit, a staff stated the residents were away at an adult day program and LPA Marrufo did not observe residents to be present during visit.

During visit, LPA Marrufo toured the facility inside and out. The kitchen area had a locked cabinet for sharps and cleaning supplies. The food storage areas in the kitchen, pantry, and garage had a perishable food supply of at least two days and a non-perishable food supply of at least seven days. The first aid kit was complete.

4 out of 4 bedrooms had working lights and available bed and clothing storage. The smoke detector system functioned properly when tested. The carbon monoxide detector functioned properly when tested. 2 out of 2 resident bathrooms had available soap and paper towels and had functioning lights. Anti-slip mats were observed to be in the showers. The water temperatures in the bathroom sinks were 110 F and 111 F.

The outdoor area was toured and the outdoor exit was clear of obstructions.

Resident and staff records, including Centrally Stored Medication Logs and Personal and Incidental Money logs, were reviewed and found to be complete. The Emergency Disaster Drill Log recorded a disaster drill from January 22nd, 2024.

No deficiencies were cited at this time.


This report was reviewed with Red Dionio and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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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