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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202925
Report Date: 01/16/2025
Date Signed: 01/16/2025 10:59:00 AM

Document Has Been Signed on 01/16/2025 10:59 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/
DIRECTOR:
DUMANTAY, ERWINFACILITY TYPE:
735
ADDRESS:3942 HOMEPARK CTTELEPHONE:
(408) 728-5505
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 0DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Administrator Erwin DumantayTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Erwin Dumantay. During the visit, LPA observed 0 residents and 1 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 3 residents bedrooms. The staff bedroom inside the facility was also inspected. The front yard and backyard were inspected. While touring the backyard, LPA observed and toured facility staff accessory dwelling unit, which is for staff use only. LPA also toured the facility garage, which is being used as a storage space/Laundry area. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 65 degrees F, and hot water temperature was measured to range from 106-109 degrees F in resident bathrooms.

Fire extinguisher was serviced in January 16, 2025. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log.

LPA reviewed facility records for 1 staff. As of January 16, 2025, the facility does not have any residents. ADM stated the facility is still in the vendorization process with San Andreas Regional Center.

No deficiencies cited during today's visit. This report was reviewed with Administrator Erwin Dumantay and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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