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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202864
Report Date: 05/02/2022
Date Signed: 05/03/2022 11:20:26 AM

Document Has Been Signed on 05/03/2022 11:20 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:IFUR'S CARE HOMEFACILITY NUMBER:
435202864
ADMINISTRATOR:MENDINUETO, VERONICAFACILITY TYPE:
735
ADDRESS:2861 LONGACRE COURTTELEPHONE:
(408) 998-9020
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 0DATE:
05/02/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Veronica MendinuetoTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Prelicensing visit and met with Veronica Mendinueto Applicant/Administrator and Ifur Batoan Assistant Administrator and toured the facility inside and out.

The facility consists of 5 bedrooms, 2 staff and 3 resident rooms. Fire exit routes were free and clear of obstructions. Combination Smoke and Carbon monoxide Detectors interconnected were tested and functioning. Fire extinguisher was last inspected on 12/21/2021. Each resident bathroom hot water temperatures ranged from 113.5 F to 116.6 F. Each bathroom had showers with grab bars. Each bedroom had functioning lights. First Aid Kit complete.

Sharp objects and knives and medications to be secured in locked drawer and cabinet in the kitchen. Toxins, cleaning supplies and laundry detergents are to be secured in locked cabinets inside the garage area.

LPA reviewed the Component III Presentation with Veronica Mendinueto Applicant/Administrator.

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 Veronica Mendinueto Applicant/Administrator and Ifur Batoan Assistant Administrator 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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