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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202913
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:23:24 AM

Document Has Been Signed on 11/14/2024 11:23 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/
DIRECTOR:		MESA, GLEENFACILITY TYPE:
735
ADDRESS:5821 INDIAN AVENUETELEPHONE:
(408) 655-1226
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 0DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Licensee, Ebadat, FarnooshTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Licensee, Ebadat, Farnoosh. LPA Rai did not observe staff or residents at the facility. This facility is currently non-operational.

LPA Rai observed the facility inside and outside. LPA Rai observed the exits were clear of obstruction.

LPA Rai observed 4 resident rooms, 1 staff room and 2 living rooms, kitchen and garage. LPA Rai observed food supply of 2 days of perishable foods and 7 days of non-perishable foods. LPA Rai observed emergency food supply for at least 3 days. LPA Rai observed locked cabinets for chemicals, medications and sharp objects.

LPA Rai measured the hot water temperature for 2 out of 2 bathrooms which read between 119.2 - 119.7 degrees Fahrenheit. Carbon monoxide detectors and smoke alarms are in working condition.

Licensee, Ebadat, Farnoosh agreed and understood to continue to pay the annual fee and facility cannot be rented out as the location is still a licensed facility. Licensee, Ebadat, Farnoosh agreed and understood that the facility is in active status, therefore, they are not exempted from adhering to Title 22, Division 6 Policy, Regulations, and Laws.

LPA Rai advised Licensee, Ebadat, Farnoosh to inform the Community Care Licensing Regional Office when the first resident has been admitted to the facility.

No deficiencies were cited at this time as per California Code of Regulations, Title 22.
This report was reviewed with Licensee, Ebadat, Farnoosh and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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