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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202926
Report Date: 08/13/2024
Date Signed: 08/13/2024 04:41:10 PM

Document Has Been Signed on 08/13/2024 04:41 PM - 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:MAPLEWOOD MANORFACILITY NUMBER:
435202926
ADMINISTRATOR/
DIRECTOR:		VICENTE, ROGELIOFACILITY TYPE:
735
ADDRESS:3281 HEBRON CTTELEPHONE:
(650) 776-9173
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 4CENSUS: 0DATE:
08/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Licensee Christopher PatioTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On August 13, 2024,  Licensing Program Analyst (LPA) Manuel Monter, conducted an announced pre-licensing inspection and met with Licensee (LN) Christopher Patio.

The facility is an Adult Residential Facility, Level 4C. The facility fire clearance is approved for 4 ambulatory. At the time of inspection there are 0 clients observed.

LPA and LN toured the facility inside and outside,  which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The front yard and backyard were inspected. There was no obstruction to block the walkways.

The facility has 2 designated exit routes per LIC 610D (emergency and disaster plan); Main front entrance and Right back side of the house. The exits are free from obstruction. The facility has carbon monoxide and smoke alarm detectors  that are strategically placed throughout the building.  The facility fire extinguishers are placed strategically in the underneath the kitchen sink and inside the garage.  The fire extinguishers were serviced on December 2023. 

The laundry area is located in the garage. The laundry detergents, cleaning supplies and other toxic are locked and can only be accessed by staff. 

3 Out of 3 resident bedrooms have adequate lighting, bed frames with mattress, linens, lamps, night stands, drawer dresser storage and closet space that is sufficient to store clients’ personal belongings.

2 Out of 2 bathrooms hot water temperature measured 118 degrees Fahrenheit. Room temperature is at 78 degree F. The facility has a centralized air-conditioning system.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: MAPLEWOOD MANOR
FACILITY NUMBER: 435202926
VISIT DATE: 08/13/2024
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Medication closet observed to be locked. First Aid kit was observed, which contained first aid supplies, with manual, tweezers and scissor. Facility kitchen equipment is functioning properly, LPA observed storage shed for sharps. LPA reviewed emergency disaster plan and confirmed its completeness. LPA observed cleaning products and chemicals locked an inaccessible to residents in care. 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 Licensee Christopher Patio. This report was reviewed with Licensee Christopher Patio and a copy of the report was provided.

END OF REPORT

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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