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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202825
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:42:05 PM

Document Has Been Signed on 11/03/2022 02:42 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:SAN JOAQUIN HOME 1FACILITY NUMBER:
435202825
ADMINISTRATOR:LAUREL, PATRICKFACILITY TYPE:
735
ADDRESS:4770 CALLE DE TOSCATELEPHONE:
(408) 439-2636
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 5DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cheryl TanTIME COMPLETED:
02:47 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Cheryl Tan
During visit, LPA Marrufo toured the facility inside and out. LPA observed the visitor screening area. LPA Marrufo observed a 30-Day supply of PPEs. LPA Marrufo observed a a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. LPA Marrufo observed the bathrooms to have available soap, paper towels, and hand washing signs.

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

This report was reviewed with Cheryl Tan and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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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