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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202868
Report Date: 04/05/2024
Date Signed: 07/26/2024 05:27:43 PM

Document Has Been Signed on 07/26/2024 05:27 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MMS MANOR IIFACILITY NUMBER:
435202868
ADMINISTRATOR/
DIRECTOR:		VALERA, STEPHANIEFACILITY TYPE:
735
ADDRESS:5824 CAHALAN AVETELEPHONE:
(408) 365-8281
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
04/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Lance Alday Staff/Designated AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 4/5/2025 at 3:00 PM Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived unannounced to conduct an annual required inspection. LPA met with staff and designated administrator Lance Alday. Administrator (ADM) Stephanie Valera was currently unavailable. Staff called ADM, ADM stated she was driving and on her way to her Gilroy. ADM stated staff Lance Alday is authorized to sign reports and accompany LPA when touring the facility in her absence.

The facility temperature measured at 70 degrees F. The hot water temperature was tested in the hall bathroom and measured at 111.7 to 112 degrees F. There were working lights in each room. There are grab bars for each toilet and shower. Bathrooms had non-skid mats. Supplies of personal hygiene items were available. The facility has a functioning smoke and carbon monoxide detectors that was tested during the visit. Fire Extinguishers were inspected on 6/20/2023 The last emergency disaster drill was on 9/3/2023. Medications are stored in a locked cabinet in the office. Knives are locked in a drawer in the kitchen. Toxins and cleaning supplies are locked in a cabinet in the garage.

Bedrooms were observed with appropriate furniture and in good repair. Kitchen area was observed clean and sanitary. 2 days’ worth of perishables and 7 days’ worth of nonperishable were observed. LPA observed that interior hallways, and outdoor walkways are free from debris and obstruction.

Facility staff all have criminal record clearance to work at the facility and are associated to the facility. Staff records have the following personnel record, health screening with TB test information, criminal record statement, and current first aid certificate.

page 1 continued to page 2 (LIC 809C)
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MMS MANOR II
FACILITY NUMBER: 435202868
VISIT DATE: 04/05/2024
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 Resident records have the following admission agreement, medical assessment with TB test information, updated needs and services plan, and personal rights.

The following forms were requested to update the facility record by 4/15/2024
LIC 500 Personnel Record
Administrator Certificate
LIC 610E Emergency Disaster Plan
Surety Bond
LIC 400

Advisory note was given to the licensee during today's visit. No deficiency was cited per CCR Title 22.
An exit interview was conducted with Staff Lance Alday as the designated administrator for the facility in behalf of ADM Stephanie Valera.


end of report
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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