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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202884
Report Date: 01/17/2024
Date Signed: 01/17/2024 01:48:20 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/17/2024 01:48 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:M&K ADULT CARE LLCFACILITY NUMBER:
435202884
ADMINISTRATOR:ZAREGHBEITI, KHOSROWFACILITY TYPE:
735
ADDRESS:5527 CENTURY MANOR COURTTELEPHONE:
(408) 621-6871
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 0DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marjan GholizadehTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Marjan Gholizaveh.

During visit, Ms. Gholizadeh stated that there are no clients at the facility and none have ever been admitted yet.

LPA Marrufo toured the facility and did not find any residents at the facility.


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

This report was reviewed with Ms. Gholizadeh and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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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