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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202798
Report Date: 01/22/2025
Date Signed: 01/29/2025 09:50:35 AM

Document Has Been Signed on 01/29/2025 09:50 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/
DIRECTOR:
CANLAS, AVELINO R JR.FACILITY TYPE:
735
ADDRESS:512 CENTURY OAKS WAYTELEPHONE:
(408) 823-7168
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 5DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rogelio DionioTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Lead Staff Rogelio Dionio.

During visit, LPA toured the facility inside and out. LPA toured the kitchen area and observed locked cabinets for sharp objects, medications, and cleaning supplies. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least 7 days in the facility refrigerators and pantry areas. LPA reviewed the first aid kit and found it to be complete.


LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and working lights. The showers had anti-slip mats and showering chairs. The water temperatures in the bathroom sinks were 116 F and 117 F.

During visit, staff tested the centralized smoke detection system and it functioned properly when tested. LPA tested two out of two carbon monoxide detectors and each one functioned properly when tested.

LPA toured three out of three resident rooms. Each room had working lights and available bedding and clothing storage areas. LPA toured the outside area and the outdoor exit was clear of obstructions.

LPA reviewed the Personal and Incidental Money Log for 5 out of 5 residents and the Centralized Medication Log for 5 out of 5 residents. All logs were balanced and complete during review. LPA reviewed 5 out of 5 resident records and 5 staff records and all records were complete. The Emergency Disaster Drill Log indicates the last drill was conducted on 12/23/2024.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Lead Staff Rogelio Dionio and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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