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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202853
Report Date: 05/24/2022
Date Signed: 05/24/2022 10:54:42 AM

Document Has Been Signed on 05/24/2022 10:54 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:EMANUEL'S CARE HOME #2FACILITY NUMBER:
435202853
ADMINISTRATOR:GONZALEZ, DORISFACILITY TYPE:
735
ADDRESS:6047 SAN YSABEL WAYTELEPHONE:
(408) 592-5303
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
05/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Doris GonzalezTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) David Marrufo conducted a Prelicensing visit and met with Doris Gonzalez.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the hallways, 3 out of 3 resident rooms, hallway bathroom, kitchen area, and outside areas. The exits in the outside areas were free of obstructions. The hallway bathroom had hand washing signs and the water temperature in the sink was measured at 112 F. LPA Marrufo observed a 30-day supply of PPEs, a perishable food supply of at least 2 days and an at least 7 day supply of non-perishable foods. LPA Marrufo reviewed resident and staff records.

LPA Marrufo reviewed Component III with Administrator Doris Gonzalez.


No deficiencies were cited at this time as per California Code of Regulations Title 22. A Technical Advisory was issued. See LIC9102 for more information.


This report was reviewed with Administrator Doris Gonzalez and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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