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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294284
Report Date: 06/28/2022
Date Signed: 08/22/2022 11:37:32 AM


Document Has Been Signed on 08/22/2022 11:37 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:ST. MARY'S RESIDENTIAL CARE HOME IIFACILITY NUMBER:
435294284
ADMINISTRATOR:ARIMAS, MARILUZ & MERLINOFACILITY TYPE:
740
ADDRESS:1265 SOCORRO AVENUETELEPHONE:
(408) 390-4931
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:6CENSUS: 5DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Joseph Bryan CastanedaTIME COMPLETED:
12:00 PM
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On 06/28/2022, Licensing Program Analysts (LPAs)Mandeep Kaur and David Marrufo conducted an unannounced infection control site visit today. LPAs met with Care Giver Joseph Bryan Castaneda.

A temperature screening station, sign in sheet, and COVID-19 questionnaire were present at the entrance. Hand sanitizing stations were present. LPAs were checked in by the Care giver before the tour. LPAs toured the facility with Care Giver.

All staff members were observed to be wearing masks.

2 out of 2 common restrooms observed to be adequately stocked with hand soap and towels are provided to the residents by the staff and put it in the laundry for disinfection.

The main kitchen was inspected. There was sufficient perishable food for at least 2 days and nonperishable food for at least one week.

Facility was observed to have adequate supply of PPE.

5 of the 5 residents bedrooms were observed. Outside of the facility was observed.
.
No deficiency cited during visit.

This report was reviewed with nd a copy of Joseph Bryan Castaneda and Administrator Marilluz Arimas report was provided
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 726-4986
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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