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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803154
Report Date: 02/13/2025
Date Signed: 02/13/2025 03:58:17 PM

Document Has Been Signed on 02/13/2025 03:58 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAN JOSE CARE HOMEFACILITY NUMBER:
486803154
ADMINISTRATOR/
DIRECTOR:
LALIC, CORAZONFACILITY TYPE:
735
ADDRESS:1024 BUCHANAN STREETTELEPHONE:
(707) 425-3950
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 3DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Corazon Lalic, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analysts (LPA’s) Shannan Hansen & Ethel Contreras arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA’s met with Facility Administrator, Corazon Lalic and explained the purpose of the visit. Facility is a single story, 5 bedroom (1 caregiver’s), 2 bathrooms, with fire clearance for 4 ambulatory, 2 of which may be Non-Ambulatory (bedrooms 1 & 2).

On 2/13/2025 at aprox 8:35 LPA’s and Administrator toured facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, sheds (additional new shed added 9/2024 -sketch provided), and common restrooms. LPA's observed all walkways and exits to be unobstructed. Toxins are secure and not accessible to clients. LPA’s observed facility to be clean, in good repair and odor-free. Medication is centrally stored and secure in locked closet across from kitchen. There is a sufficient supply of hygiene products and linens on hand for client use. LPA’s observed each bedroom to have the necessary furnishings and all lights in working order. Clients bathrooms had required slip resistant mats and grab bars or shower chair.

Facility has a supply of 2-day perishable and 7-day non-perishable amount of food as required by regulations. Sharps, toxic chemicals & medications were observed to be locked. Hot water temperature was measured at 116.9 F. LPA's observed one (1) fire extinguisher last charged/ inspected 7/23/2024. Fire detectors, and carbon monoxide detectors were tested and in working order. Disaster Drills are conducted twice yearly, with the last drill conducted 1/4/2025.

In the areas toured no immediate health, safety, or personal rights violations were observed.

At approximately 9:00 AM, LPA’s reviewed 3 of 3 client records and 3 of 3 staff records, all found to be thorough and contained required documentation. First aid & CPR certification was current in staff files reviewed. Facility only handles PI’s monies for one client which were documented, secured, & not commingled. Spot review of medications conducted, found to be accurate. Administrator's Certificate for Corazon Lalic # 7032710735 expires 1/12/2026.


Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAN JOSE CARE HOME
FACILITY NUMBER: 486803154
VISIT DATE: 02/13/2025
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Continued from LIC809-

No deficiencies cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

LPA’s are requesting Licensee to submit updated documents to CCL by 2/27/2025

LIC500- Personnel Report


LIC308- Designation of Responsibility
LIC400 – Cash Resources
LIC610- Disaster Plan (if changes)
Permit for new storage shed
Surity Bond
Copy of Admin Certificate
LIC 9020 Register of Facility Client’s
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
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