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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202848
Report Date: 12/02/2021
Date Signed: 12/02/2021 09:42:24 AM

Document Has Been Signed on 12/02/2021 09:42 AM - 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:JADENS ARF LLCFACILITY NUMBER:
435202848
ADMINISTRATOR:PEREZ, JOCELYNFACILITY TYPE:
735
ADDRESS:5914 TANDERA AVENUETELEPHONE:
(650) 278-1110
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 0DATE:
12/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jocelyn PerezTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) David Marrufo conducted a Prelicensing visit and met with Administrator Jocelyn Perez.

During visit, LPA Marrufo observed that there were no residents yet at the facility. LPA Marrufo toured 5 out of 5 bedrooms and observed each bedroom to have furniture, bedding, and available lighting. The facility bathroom had a hand washing sign, available soap and paper towels, and trash bin. The facility has a medication cart that is locked. LPA observed locked cabinets for disinfectants and other supplies. The indoor and outdoor pathways were clear of obstructions.

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

This report was reviewed with Administrator Jocelyn Perez and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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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