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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202870
Report Date: 10/03/2022
Date Signed: 10/03/2022 10:28:24 AM

Document Has Been Signed on 10/03/2022 10:28 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:DIGNITY CARE HOMEFACILITY NUMBER:
435202870
ADMINISTRATOR:SUNGLAO, BERNARDINO P.FACILITY TYPE:
735
ADDRESS:3899 MARE PLACE CTTELEPHONE:
(909) 205-0891
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 0DATE:
10/03/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bernardino SunglaoTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) David Marrufo conducted a Prelicensing visit and met with Administrator Bernardino Sunglao and Chief Financial Officer Kishan Sreedhar.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo toured the kitchen area and observed there to be locked drawers for sharps and cleaning supplies. The hallway has a locked storage area for storing medications. The facility garage had locked storage areas for storing resident and staff records. The hallway bathroom had a paper towel dispenser and the water temperature measured at 118 F. 3 out of 3 bedrooms had available lights, bedding, and drawers. The outdoor area exit was cleared of obstructions. The carbon monoxide and fire detectors were tested and found to be functioning properly.

No residents were observed during visit.

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

During visit, LPA Marrufo reviewed Component III presentation with Administrator Sunglao.

This report was reviewed with Administrator Sunglao and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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