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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202826
Report Date: 09/08/2023
Date Signed: 09/08/2023 12:24:49 PM

Document Has Been Signed on 09/08/2023 12:24 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:LOUPE ADULT RESIDENTIAL FACILITY INC.FACILITY NUMBER:
435202826
ADMINISTRATOR:AUDREY ANN SALVADORFACILITY TYPE:
735
ADDRESS:1257 LOUPE AVENUETELEPHONE:
(408) 620-1254
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 4CENSUS: 4DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cecilia Valenzuela Administrator TIME COMPLETED:
12:30 PM
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Licensing Program Analyst Manuel Monter (LPA) conducted an unannounced annual inspection on 09/08/2023. LPA met with facility Administrator Cecilia Valenzuela (ADM).

LPA toured the facility inside and out; which included the living room, kitchen, dining room, laundry room, 4 resident bedrooms, 2 staff bedrooms, 2 bathrooms, backyard, and shed. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication cabinet, sharps storage lock box, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degree F, and hot water temperature was measured to 110 degrees F in both bathrooms. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on August 8th 2023. Fire extinguishers observed to be inspected in May 2023. Fire alarm tested and observed to be functioning properly.

LPA reviewed facility records for 2 staff and 2 residents. LPA reviewed 2 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff. (S1 to S2) Residents were are day program during LPA's Annual visit and could not be interviewed.

No deficiencies cited during today's visit. This report was reviewed with Administrator Cecilia Valenzuela and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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