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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202927
Report Date: 05/10/2024
Date Signed: 05/10/2024 12:06:32 PM

Document Has Been Signed on 05/10/2024 12:06 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:CASA DE REYESFACILITY NUMBER:
435202927
ADMINISTRATOR/
DIRECTOR:		MIRANDA, LEOFELMAFACILITY TYPE:
735
ADDRESS:7566 ALEXANDER STREETTELEPHONE:
(408) 848-6672
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 5DATE:
05/10/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Michella Villarreal, Applicant
Leofelma Miranda, Administrator		TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Component II completion: Successful

Facility Type: Adult Residential Facility (ARF)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 5
COMP II Participants: Michelle Villarreal, Applicant
Leofelma Miranda, Administrator
Interview Method: Telephone interview

On May 10, 2024, applicant and administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicant and Administrator. Report sent via email and informed to return signed copy to CAB by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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