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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202827
Report Date: 10/25/2021
Date Signed: 10/25/2021 04:47:26 PM

Document Has Been Signed on 10/25/2021 04:47 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:SAN JOAQUIN HOME 2FACILITY NUMBER:
435202827
ADMINISTRATOR:LAUREL, PATRICK M.FACILITY TYPE:
735
ADDRESS:4790 CALLE DE TOSCATELEPHONE:
(408) 439-2636
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 4DATE:
10/25/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Patrick LaurelTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPA) Joanne Roadilla and Steve Chang conducted a pre-licensing inspection today for a change of ownership. LPA met with licensee Patrick Laurel and home Administrator (ADM) Christine Lee. The home currently has 4 residents.

At around 2:00pm, LPAs toured the facility inside and out. The facility is equipped with smoke and carbon monoxide detectors. Fire extinguisher observed in the home which were all serviced on 06/20/21. The kitchen, dining and living room were observed in good repair.

Resident bedrooms were observed in good repair, furnished, with clean linens and adequate lighting. Bathrooms were observed clean and equipped with grab bars. The water temperature in the kitchen was measured at 101.5 degrees F. Centrally stored medication cabinet with first aid kit was observed locked. 2-day perishable and 7-day non-perishable food were observed in the kitchen. All outdoor and indoor passageways were observed clear and free of obstruction. The backyard was inspected, no bodies of water observed.

LPAs reviewed 4 resident files and 4 staff files. Facility staff are fingerprint cleared and associated to the facility. Resident files all consist of Admission Agreement, Appraisal Needs and Services Plans and Functional Capability Assessment forms.

Component III orientation was completed with licensee. No issues noted during the pre-licensing tele-inspection. The physical plant is approved pending the completion of Centralized Application Bureau (CAB) review of the facility application. Exit interview conducted with and copy of report provided to Patrick Laurel and Christine Lee.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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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