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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202918
Report Date: 09/18/2024
Date Signed: 09/18/2024 11:23:57 AM


Document Has Been Signed on 09/18/2024 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:UMBRELLA RESIDENTIAL CAREFACILITY NUMBER:
435202918
ADMINISTRATOR:VALLARTA, ANABELEN D.FACILITY TYPE:
740
ADDRESS:4623 MANGRUM DRIVETELEPHONE:
(510) 709-7078
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY:6CENSUS: 0DATE:
09/18/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant, Anabelen VallartaTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Simi Rai and Marcella Tarin arrived announced to conduct the facility's pre-licensing visit. LPAs met with Applicant, Anabelen Vallarta. There are no clients present on site. This facility address is not currently licensed.

During visit, LPAs toured the inside and outside of the facility to include the kitchen, dining, living room, garage, activity room, 3 resident rooms, 1 staff room, 1 office room and 3 bathrooms. All fire exit routes were free and clear of obstruction. LPAs observed 2 sheds in the backyard which will be used for storage and not habitual space. Toxins observed secured. Facility has an approved fire clearance for 3 ambulatory, 2 non ambulatory residents and 1 bedridden resident in Bedroom #2.

Bathrooms supplied with hygiene products and paper supplies. LPAs observed the smoke and carbon monoxide detectors to be in working condition. Hot water temperature maintained between 108.9 - 109.4 degrees Fahrenheit. Facility temperature maintained at 70 degrees Fahrenheit. First aid kit supplied with tweezers, bandages, gauze, scissors, and thermometer. Medications will be stored in a locked cabinet. The facility will lock sharp supplies in a locked cabinet in the kitchen. The following posters observed to include the emergency telephone numbers, personal rights, and facility sketch. Fire extinguisher was inspected on 08/28/2024.

No issues noted during this pre-licensing inspection.
COMP III was reviewed during visit.
LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Applicant, Anabelen Vallarta. A copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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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