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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202826
Report Date: 08/25/2021
Date Signed: 08/25/2021 12:07:06 PM

Document Has Been Signed on 08/25/2021 12:07 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LOUPE ADULT RESIDENTIAL FACILITY INC.FACILITY NUMBER:
435202826
ADMINISTRATOR:VALENZUELA, JALANOFACILITY TYPE:
735
ADDRESS:1257 LOUPE AVENUETELEPHONE:
(408) 620-1254
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 4CENSUS: 0DATE:
08/25/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alyssa and Jalano, ValenzuelaTIME COMPLETED:
12:15 PM
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At approximately 10:00 AM, Licensing Program Analyst (LPA) Steve Nguyen, conducted a Pre-Licensing Inspection at facility. LPA met with Licensee Jalano and Alyssa Valenzuela; explained the purpose of the visit, and conducted an inspection of facility inside and out.

Facility’s exits were observed to be free of hazards and obstructions. The facility has an Emergency Disaster Preparedness Plan in place, including Covid 19 preparedness. Smoke and carbon monoxide detectors are in working conditions. All toxins, cleaning supplies and hazardous materials were locked in both cabinet and closet space. Water temperature in garage was checked and it was at 110 degrees. Sharp utensils were observed locked in kitchen cabinet. Fire extinguishers located in front hall way, garage, and in back yard; all extinguishers were checked on 8/21/2021 by fire marshal. Observed that facility has 3 days of perishable and 14 days Non-perishable foods on site.

Medications secured in a cabinet. First Aid kit was stocked with supplies to include but not limited to: scissors, tweezers, thermometer, and first aid manual.

At approximately 12:00 PM, review of Component III was completed.

The physical plant is approved for Licensure pending the final approval by Centralized Application Bureau (CAB). No deficiencies were cited per the California Code of Regulation Title 22.

LPA review report summary with Licensee Jalano and Alyssa Valenzuela and a copy was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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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