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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202852
Report Date: 05/02/2022
Date Signed: 05/03/2022 11:21:11 AM

Document Has Been Signed on 05/03/2022 11:21 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,
, CA
FACILITY NAME:EMANUEL'S CARE HOMEFACILITY NUMBER:
435202852
ADMINISTRATOR:GONZALEZ, DORISFACILITY TYPE:
735
ADDRESS:2053 RADIO AVETELEPHONE:
(408) 592-5303
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 5DATE:
05/02/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ester KattanTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Prelicensing visit and met with Ester Kattan Manager toured the facility inside and out. 2 residents were present and the other 3 residents were attending a Day Program.

The facility consists of 4 bedrooms, 1 staff and 3 resident rooms. The facility has fire clearance for 5 ambulatory residents and 1 non ambulatory resident. Fire exit routes were free and clear of obstructions. Interconnected Smoke Detectors and Carbon monoxide Detectors were tested and functioning. Fire extinguisher was purchased on 12/9/2021 and fully charged. The facility has fire sprinkler system installed. Each resident bathroom hot water temperatures ranged from 105.5 F to 119.7 F. Each bathroom had showers with grab bars. Each bedroom had beds with bedding, dressers, chairs, and functioning lighting.

LPA observed a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days.

LPA reviewed the Component III Presentation with Ester Kattan.

No issues noted during this Prelicensing inspection.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Ester Kattan Manager and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2022
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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