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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202920
Report Date: 02/02/2024
Date Signed: 02/02/2024 09:38:32 AM

Document Has Been Signed on 02/02/2024 09:38 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:BLISS FIVE RESIDENTIAL CARE HOME INC.FACILITY NUMBER:
435202920
ADMINISTRATOR:SANTOS, MICHELLE SFACILITY TYPE:
735
ADDRESS:978 SOUTH SECOND STREETTELEPHONE:
(408) 469-7154
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 6CENSUS: 0DATE:
02/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Michelle SantosTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) David Marrufo conducted a Prelicensing visit and met with Administrator Michelle Santos.

During visit, LPA Marrufo toured the facility inside and out. The kitchen area had a refrigerator and freezer. The office room had locked storage areas for resident records and medications. 1 out of 2 bathrooms had a locked cabinet for sharp objects and cleaning supplies.

LPA Marrufo toured 3 out of 3 resident bedrooms. Each bedroom had available bedding and dressers and had functioning lights. The facility smoke alarm was tested and found to be functional when tested. The carbon monoxide detector functioned properly when tested.

2 out of 2 bathrooms were observed. Each bathroom had available soap and paper towels and functioning lights. The bathrooms had water temperatures of 114 F and 118 F.

LPA observed a hallway bulletin board with signs, including personal rights and CCL complaint hot line information.

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

LPA Marrufo reviewed the Component III presentation with Administrator Michelle Santos during visit.

The pre-licensing is complete and this facility has no deficiencies.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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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