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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202921
Report Date: 04/03/2024
Date Signed: 04/03/2024 10:27:29 AM

Document Has Been Signed on 04/03/2024 10:27 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:GLENGROVE RESIDENTIAL CARE HOME, LLCFACILITY NUMBER:
435202921
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		DUMANTAY, ERWINFACILITY TYPE:
735
ADDRESS:3889 GLENGROVE WAYTELEPHONE:
(408) 728-5505
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
04/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
09:48 AM
MET WITH:Staff member Sally OvisoTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Manuel Monter arrived announced to conduct a follow up visit from facility's pre-licensing visit on 03/08/2024. LPA met with staff member Sally Oviso, S1. LPA called ADM. ADM stated staff Sally Oviso could sign on his behalf. LPA observed 2 residents and two staff during LPA's visit.

LPA toured the facility inside and out with staff S1. During today's visit, LPA Monter inspected the items which were unresolved during the pre-licensing visit on 03/08/2024.

LPA observed the broken glass closet sliding door in bedroom #4 has been removed and replaced with a sliding curtain. LPA observed the missing paint in bedroom #1 has been addressed. LPA observed the storage shed in the backyard is locked and inaccessible to residents in care. LPA observed the grab bar in bathroom #1 is secured. LPA observed non-skid mats in bathrooms #2 and #3. LPA observed bedroom #4 has a sliding screen door. LPA observed bedroom #6 screen is in good repair.

Pre-licensing deficiencies have been resolved. Pre-Licensing is now complete.
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 staff member Sally Oviso and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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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