<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202925
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:45:34 AM

Document Has Been Signed on 02/13/2024 11:45 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:HOMEPARK CARE HOME, LLCFACILITY NUMBER:
435202925
ADMINISTRATOR:DUMANTAY, ERWINFACILITY TYPE:
735
ADDRESS:3942 HOMEPARK CTTELEPHONE:
(408) 728-5505
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 0DATE:
02/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator Erwin DumantayTIME COMPLETED:
11:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Manuel Monter (LPA) conducted an announced pre-licensing inspection and met with Administrator (ADM) Erwin Dumantay. There are no residents present on site.

During visit, LPA toured the facility, including living room, 4 resident bedrooms, garage, kitchen/dining room 3 bathrooms, and backyard. While touring the backyard, LPA observed and toured facility staff accessory dwelling unit, which is for staff use only.

Facility was observed to be clean and in good repair. Fire exit routes were clear and free of obstructions. Carbon monoxide detectors was tested and observed to be functioning properly. Fire extinguisher was purchased in December 10, 2023. Bathroom hot water temperature was measured to range from 108- 110 degrees F. Facility temperature observed to be 65*F. Bathrooms were observed to be stocked with soap and paper towels. First Aid Kit observed to be complete. No open bodies of water noted at facility.

Medication cabinet observed to be locked. Facility kitchen equipment is functioning properly, LPAs observed locked drawer for sharps. LPAs reviewed emergency disaster plan and confirmed its completeness. LPAs observed storage closed for containment of cleaning chemicals. Facility bulletin board contain all necessary documents. No issues noted during this Pre-Licensing Inspection.

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.

Component III orientation was conducted with ADM Erwin Dumantay. This report was reviewed with Administrator (ADM) Erwin Dumantay and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1