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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294164
Report Date: 06/08/2021
Date Signed: 06/08/2021 01:15:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:JF HEALTH CARE SERVICESFACILITY NUMBER:
435294164
ADMINISTRATOR:DULAY, JAIME & FLORDELIZAFACILITY TYPE:
740
ADDRESS:1614 RALENE PLACETELEPHONE:
(408) 937-5202
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY:6CENSUS: 0DATE:
06/08/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jaime DulayTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an announced visit at the facility to confirm that the facility is no longer operating as a licensed care home and to ensure that there were no residents still living in the facility.

LPA Marrufo toured 5 out of 5 bedrooms in the facility and observed there were no residents or belongings present in the bedrooms. LPA Marrufo toured the rest of the home and found it empty of belongings as well. LPA toured the outside and garage areas.

No deficiencies were cited at this time per California Code of Regulations Title 22.

Licensee will submit the facility license to CCL.

This report was reviewed with Jaime Dulay and a copy of the report was provided.

SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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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