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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202868
Report Date: 06/28/2022
Date Signed: 06/28/2022 03:08:24 PM

Document Has Been Signed on 06/28/2022 03:08 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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:
06/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cora PaduaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Prelicensing visit and met with lead staff Cora Padua.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured 3 out of 3 resident bedrooms and observed each bedroom to have lighting and bedding. LPA Marrufo toured 1 out of 1 resident bathrooms and observed it to have available soap and paper towels and a hand washing poster. The facility bathroom water temperature measured at 110 F.

LPA Marrufo observed the kitchen area and the garage food storage areas. The facility had a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. Staff tested 1 out of 1 carbon monoxide detectors and it functioned properly when tested. The outdoor area exits were clear of obstructions. The facility had resident rights signs posted in the facility.

LPA Marrufo reviewed the staff and resident records and all were found to be complete. LPA Marrufo observed medications to be secured in a locked cabinet.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with lead staff Cora Padua and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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