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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202932
Report Date: 04/25/2024
Date Signed: 04/25/2024 11:45:37 AM

Document Has Been Signed on 04/25/2024 11:45 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:SELAH ELDERLY CAREFACILITY NUMBER:
435202932
ADMINISTRATOR/
DIRECTOR:
AWUZIE, PAULFACILITY TYPE:
740
ADDRESS:10735 N STELLING RDTELEPHONE:
(408) 661-3724
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 6CENSUS: 0DATE:
04/25/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Appliant, Lilian Awuzie and Paul AwuzieTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Simi Rai arrived announced to conduct the facility's pre-licensing visit. LPA met with Appliant, Lilian Awuzie and Paul Awuzie. There are no clients present on site. This facility address is not currently licensed.

During visit, LPA toured the inside and outside of the facility to include the anteroom, kitchen, dining, living room, garage, laundry room, 5 resident rooms and 3 bathrooms. All fire exit routes were free and clear of obstruction. Toxins observed secured. Facility has an approved fire clearance for 5 non ambulatory residents and 1 bedridden resident in Bedroom #4.

Bathrooms supplied with hygiene products and paper supplies. LPA observed the smoke and carbon monoxide detectors to be in working condition. Hot water temperature maintained between 117.1 - 117.7 degrees Fahrenheit. Facility temperature maintained at 71 degrees Fahrenheit. First aid kit supplied with tweezers, bandages, gauze, scissors, and thermometer. Medications will be stored in a locked cabinet. The facility will lock sharp supplies in a lock box in the kitchen. The following posters observed to include the emergency telephone numbers, personal rights, and facility sketch. Fire extinguisher was inspected on 02/26/2024.

No issues noted during this pre-licensing inspection.
COMP III was reviewed during visit.
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 Applicant, Lilian Awuzie and Paul Awuzie. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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