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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202868
Report Date: 06/15/2022
Date Signed: 06/15/2022 11:49:22 AM

Document Has Been Signed on 06/15/2022 11:49 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MMS MANOR IIFACILITY NUMBER:
435202868
ADMINISTRATOR:VALERA, STEPHANIEFACILITY TYPE:
735
ADDRESS:5824 CAHALAN AVETELEPHONE:
(408) 365-8281
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
06/15/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Stephanie Valera, Licensee/AdministratorTIME COMPLETED:
11:00 AM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 5
COMP II Participants: Stephanie Valera
Interview Method: Telephone interview

On June 15, 2022, Administrator participated in COMP II. Identification of the Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB Analyst confirmed Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Administrator. Report sent via email pdf and informed Administrator to return sign copy to CAB by end of business day.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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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