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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294228
Report Date: 09/23/2020
Date Signed: 09/23/2020 04:04:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:JNJJ CARE HOMEFACILITY NUMBER:
435294228
ADMINISTRATOR:WALDO, SUSANFACILITY TYPE:
740
ADDRESS:673 JENNINGS DRIVETELEPHONE:
(408) 629-7379
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:6CENSUS: 0DATE:
09/23/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Susan WaldoTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an announced facility closure visit over Facetime with Administrator Susan Waldo. The visit was conducted over Facetime due to the ongoing COVID-19 Shelter-in-Place order.

During visit, Administrator Waldo virtually toured LPA Marrufo through six out of six resident bedrooms. LPA Marrufo observed that there were no residents in any of the bedrooms and all bedrooms were clear of furniture. LPA Marrufo also viewed the outside area, kitchen, and living room. LPA Marrufo also observed a For Sale sign on the front lawn of the facility.

No deficiencies were cited at this time.

This report was reviewed with Administrator Susan Waldo. A copy of the report will be sent to her for her to sign and return to CCL.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020
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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