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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202931
Report Date: 05/24/2024
Date Signed: 05/24/2024 03:00:18 PM

Document Has Been Signed on 05/24/2024 03:00 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:LOVELY CARE HOMEFACILITY NUMBER:
435202931
ADMINISTRATOR/
DIRECTOR:		POWAR, JASVIR SINGHFACILITY TYPE:
735
ADDRESS:6487 HIDDEN CREEK DR.TELEPHONE:
(408) 766-1200
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY: 6CENSUS: 0DATE:
05/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jasvir Singh Powar - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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 Analysts (LPAs) Manuel Monter and Maria (Mita) Partoza arrived announced to conduct a pre-licensing visit and met with licensee/administrator (LIC/ADM) Jasvir Powar.

The facility is set up for an Adult Residential Facility (ARF) serving 18 years old up to 59 years of age that are developmentally disabled.

At 1:10 P.M. LPAs toured the facility with ADM including but not limited to the kitchen, dining area, visitation room, activity room, 4 bedroom, 2 bathrooms, the garage area, and the outside perimeter including backyard and side walkways. The facility's temperature is between 68 to 70 degree F.

LPA observed a locked was placed on the refrigerator door, applicant removed the lock during the time of visit. LPAs observed the knives are in a locked area. ADM stated the cabinet under the sink will not be storage for detergents or cleaning supplies.

LPAs observed 1 out of 4 bedroom will be used as a staff room, 3 out of 4 bedroom will be shared rooms allocated for residents. 1 out of 2 bathroom is located on the hallway, and 1 out of 2 bathroom is located inside the shared room with a door going to the activity room. The lower cabinet under the sink has cleaning supplies stored. ADM removed chemicals under the sink cabinet.

LPAs observed 3 shared resident bedrooms have sufficient storage for personal belongings, organized, with beddings, and ready for occupancy.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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 2
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: LOVELY CARE HOME
FACILITY NUMBER: 435202931
VISIT DATE: 05/24/2024
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
26
27
28
29
30
31
32
LPAs observed surveillance camera inside the facility on the hallways, entry way, activity room, dining area, garage and outside perimeter area of the building. LPAs observed a total of 12 surveillance cameras. ADM stated that the cameras are to be used to protect staff and residents. ADM stated 3 of the surveillance camera will be removed in the activity room, visitation room, changing the angle of the 2 surveillance camera to protect the privacy of future residents.

The laundry area is located at the garage and a locked cabinet was observed storing laundry detergents, cleaning supplies and other chemicals such as but not limited to insect repellant, glass cleaner and powder bathroom cleaner.

LPAs tested the water temperature in the kitchen and bathroom and temperature measured at 111.5 to 116.7 degree F. Fire, smoke, and carbon monoxide alarms/detectors are in good working condition.

LPAs observed a tool cabinet without a lock on the walkway with tools stored. ADM removed the gardening tools to a locked storage shed in the backyard. The walkways are free from obstruction and can be easily accessible. ADM stated that shed in the backyard originally planned to be an office will now be used as a storage area.

Pre-licensing deficiencies have been resolved. Pre-Licensing is now complete.
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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2