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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202913
Report Date: 11/21/2023
Date Signed: 11/21/2023 10:06:19 AM

Document Has Been Signed on 11/21/2023 10:06 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:FARA RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202913
ADMINISTRATOR:MESA, GLEENFACILITY TYPE:
735
ADDRESS:5821 INDIAN AVENUETELEPHONE:
(408) 655-1226
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 0DATE:
11/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Farnoosh EbadatTIME COMPLETED:
10:15 AM
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Licensing Program Analysts (LPA) David Marrufo and Maria "Mita" Partoza conducted a Pre-Licensing visit and met with Farnoosh Ebadat, Licensee.

During visit, LPAs toured the facility inside and out. LPAs observed the kitchen area and observed the first aid kit was complete. LPAs observed locked storage areas for cleaning supplies, sharp objects, and medications.

LPAs toured 1 out of 1 hallway bathrooms and observed the bathroom to have functioning lights, grab bars, anti-slip shower flooring, available soap, and water temperature of 110 F.

LPAs observed 4 out of 4 bedrooms and observed each bedroom to have functioning lights, available bedding, and furnishing.

The facility smoke detectors and carbon monoxide detector were tested and found to be functional.

The outdoor area was toured and the exits were found to be clear of obstructions.

LPAs reviewed Component III Presentation with Licensee Farnoosh Ebadat during visit.

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

This report was reviewed wit Licensee Farnoosh Ebadat and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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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