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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202865
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:34:06 PM

Document Has Been Signed on 04/21/2022 04:34 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,
, CA
FACILITY NAME:DURALIZA MANOR IIFACILITY NUMBER:
435202865
ADMINISTRATOR:ARANZASO, RHONALDFACILITY TYPE:
735
ADDRESS:695 ROYAL GLEN DRIVETELEPHONE:
(408) 223-1657
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 0DATE:
04/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Aida Pendon and Ian Sumbi TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Prelicensing visit and met with Aida Pendon Applicant and Ian Sumbi Administrator/Lead Staff and toured the facility inside and out.

The facility consists of 5 bedrooms, 2 staff and 3 resident rooms. The facility has fire clearance for 4 ambulatory residents and 2 non ambulatory residents. Non ambulatory residents cleared to occupy rear master bedroom with exterior exit door. All exterior exit doors are alarmed. Fire exit routes were free and clear of obstructions. Combination Smoke and Carbon monoxide Detectors interconnected and were tested and functioning. Fire extinguisher was last inspected on 12/3/2021. Each resident bathroom hot water temperatures ranged from 111 F to 112 F. Each bathroom had showers with grab bars and mats. Each bedroom had beds with bedding, night stands, lamps, chairs, and functioning lighting. First Aid Kit complete.

LPA observed a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. Fresh fruit of bananas were on the counter in the kitchen.

LPA reviewed the Component III Presentation with Aida Pendon Applicant.

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 Aida Pendon Applicant and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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