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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202927
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:53:16 AM

Document Has Been Signed on 06/12/2024 11:53 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: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:
06/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Michelle VillarrealTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's pre-licensing inspection visit. LPA met with Michelle Villarreal.

This is a change of ownership and the facility is currently serving 5 developmentally disabled adults. Facility has a fire clearance of 6 ambulatory residents where 4 may be non-ambulatory in room #1 and room #2.

LPA toured the interior and exterior with Michelle Villarreal and staff to include the living room, resident rooms, bathrooms, staff room, office, kitchen, dining room, laundry, and backyard. The facility sketch submitted to the Department matches LPAs tour. The facility does not have a shed or a garage. All fire exits are free and clear of obstruction. Facility temperature maintained at 71 degrees Fahrenheit. No residents observed on-site.

Resident bedrooms equipped with beds, linens, night stands, and adequate lighting. Room #1 and #2 observed with working sliding doors that leads into the backyard's emergency exit area which is equipped with a ramp and grab bars. Bathroom shower equipped with non-slip mats, a chair, and grab bars. Hot water temperature maintained at 106 degrees Fahrenheit. Facility has extra linens and blankets. The hallway has adequate lighting. Facility has dual carbon monoxide detectors and fire alarms.

Kitchen equipped with clean plates, bowls, cups, and utensils. Facility has 2 days worth of perishables and 7 days worth of non-perishables. Refrigerator temperature maintained at 28 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Sample menu posted on the refrigerator. Chemicals, sharp objects, and medications observed secured in the kitchen area. Fire extinguisher located in the kitchen last serviced in July 2023. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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: CASA DE REYES
FACILITY NUMBER: 435202927
VISIT DATE: 06/12/2024
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LPA reviewed 3 residents files were maintained and complete. Resident (R3)'s updated physician's report form June 2024 did not include an ambulatory status. Facility plans to follow-up with R3's physician to update R3's ambulatory status. LPA reviewed 3 residents P&I money, centrally stored medication and centrally stored medication records were properly maintained.

Facility has a current infection control plan and emergency disaster plan. Emergency disaster plan posted in the hallway. Facility has emergency lighting and batteries. Facility has a large bag which contains a first aid kit and emergency supplies for the residents. Emergency drills are conducted quarterly.

Posters and signs observed to include but not limited to infection control, personal rights, emergency disaster plan.

COMP III reviewed with Michelle Villarreal.

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 Michelle Villarreal and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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