435202826-3-30-2026-26-AS-MMOR-DSNU67-20260330151753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202826
Report Date: 03/30/2026
Date Signed: 03/30/2026 03:18:00 PM

Document Has Been Signed on 03/30/2026 03:18 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/ DIRECTOR:	CECILIA VALENZUELA		FACILITY TYPE:	735
ADDRESS:	1257 LOUPE AVENUE		TELEPHONE:	(408) 620-1254
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY: 4		CENSUS: 4	DATE:	03/30/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Administrator Cecilia Valenzuela		TIME VISIT/ INSPECTION COMPLETED:	03:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management-incident regarding an incident Resident R1 was struck by R2. LPA Monter met with Administrator Cecilia Valenzuela and stated the purpose of today's visit. LPA observed 3 staff and 3 residents. Loupe ARF is a level 6 home. On March 23, 2026, the Department received an incident report, regarding resident R1, which stated the following. During a community walk, residents R1 and R2 were accompanied by another resident, three staff members, and the facility dog. While walking, R1 suddenly grabbed the dog’s leash from R2. This upset R2, who then hit R1. Staff intervened immediately and separated both residents. R1 sustained a scratch on his/her left forearm; first aid was provided. R2 also sustained a scratch on his/her right elbow caused by the leash being pulled; first aid was provided. Prior to the walk, it had been agreed that R2 would hold the dog’s leash during the outing, and R1 would have his/her turn on the walk back to the Home. On March 23, 2026, Licensing Program Analyst Manuel Monter interviewed ADM. ADM stated regarding the incident, Residents R1, R2 and R3 went with 3 staff on a walk with the dog. R3 went ahead with a staff following. ADM stated before leaving the home, the residents were in agreement, that they would take turns walking the dog (1 turn going to the park and 1 turn, walking back to the care home). ADM stated when R1 and R2 (followed by 2 staff) were walking, R2 suddenly grabbed the leash from R1. ADM stated as a result, R1 hit R2, on the left fore arm. The staff intervened and separated the two residents. ADM stated they checked the injuries and evaluated them as superficial and grazed the skin.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
	VISIT DATE: 03/30/2026

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ADM the home conducted a residents council to discuss on how to schedule when walking the dog to ensure everyone has a turn. (ADM provided documentation to LPA.) ADM stated she has also discussed with staff to continue their vigilance with R1 and R2 to ensure their health and safety. ADM stated that the care home has been in communication of the ongoing care with the residents family and the residents service coordinator.

No deficiencies cited during today's visit. This report was reviewed with Administrator Cecilia Valenzuela and a copy of the signed report was provided.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026

LIC809 (FAS) - (06/04)

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