<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202910
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:31:13 PM

Document Has Been Signed on 10/26/2023 04:31 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:MANFRED CARE HOME LLCFACILITY NUMBER:
435202910
ADMINISTRATOR:DUMANTAY, MADONNAFACILITY TYPE:
735
ADDRESS:2389 RENFIELD WAYTELEPHONE:
(408) 818-0134
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
10/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Administrator, Madonna DumantayTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Simi Rai arrived announced to conduct the facility's pre-licensing visit. LPA met with Applicant, Madonna Dumantay. This location has an operating facility and LPA Rai observed 3 residents and 6 staff present at the facility.

The facility is one story home. The facility has an approved fire clearance for 2 non ambulatory residents and 4 ambulatory residents.

LPA toured the facility inside and outside including the apartments, bathrooms, kitchen, dinning room and common areas. Resident rooms were equipped with proper furniture and lighting. Facility temperature maintained at 70 degrees Fahrenheit. Bathrooms are equipped with grab bars, nonskid floors, hygiene supplies, and toiletry. The facility has designated medication rooms with locked medication cabinets. LPA observed first aid kit with the following supplies: bandages, scissors, tweezers, and thermometer. LPA Rai observed supplies of 2 days of perishable and 7 days of non-perishable supplies.

During today's visit, LPA Rai observed a shed unit being occupied as a habitual space in the backyard which was not on the LIC 999 Facility Sketch. LPA Rai observed room with bed mattress and personal items along with a functional bathroom which included a toilet, sink and shower. Applicant flushed the toilet and the water passed through and the water tank filled up. LPA Rai turned on the faucet and water poured into the sink without restriction. Applicant stated the unit was built around December 2022/January 2023 as a studio. LPA Rai observed an electric power plug extending from inside the unit and connecting with a power plug coming outside the resident's window of the facility building.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: MANFRED CARE HOME LLC
FACILITY NUMBER: 435202910
VISIT DATE: 10/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2 of 2.

Applicant stated the city did not provide a permit for buildings that cover 120 square foot in space. LPA Rai, Applicant, S3 and S4 measured the unit and it measured 14 feet 6 inches by 10 feet 6.5 inches. Applicant stated she has decided to demolish the unit and it will be removed by Monday, November 6th 2023. Applicant will submit an updated LIC 999 Facility Sketch which will include the remove of the tool shed that is drawn on the facility sketch that no longer exists on the facility property. Applicant understood the unit will be no longer be available to use.

LPA Rai observed a bed in the garage being blocked off by a storage wire shelving unit on wheels and shower curtain and blanket being used as a makeshift wall. LPA Rai observed a clear box of clothes and S1 stated it belong to him/her and S1 used the bed to sleep. LPA Rai observed 3 black cabinets which contained S2's personal items. S2 stated he/she used the bed to sleep overnight. Applicant acknowledged the bed and personal items belonged to S1 and S2. Applicant understood the garage will be no longer available to use as a bedroom.

Pre-Licensing is incomplete with deficiencies to be resolved by Monday, November 6th 2023. A follow up Pre-licensure LIC 809 will be generated upon resolution of deficiencies.

This report was reviewed with Applicant, Madonna Dumantay and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2