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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804272
Report Date: 10/18/2024
Date Signed: 10/18/2024 11:57:59 AM

Document Has Been Signed on 10/18/2024 11:57 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAN JOSE CARE HOME IIFACILITY NUMBER:
486804272
ADMINISTRATOR/
DIRECTOR:
LALIC, CORAZONFACILITY TYPE:
735
ADDRESS:1998 DIAMOND WAYTELEPHONE:
(415) 265-0870
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 0DATE:
10/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Applicant, Corazon Lalic TIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived announced to conduct a Pre-Licensing Inspection and met with Applicant, Corazon Lalic. Upon arrival, LPA was informed that there were currently no clients in care. Facility received an approved fire clearance dated 09/16/2024 that allows for a total capacity of 4 clients, where 2 can be ambulatory, 1 can be non-ambulatory, and 1 can be bedridden. Facility plans to care for adults with intellectual and developmental disabilities.

LPA conducted a walk-though of facility with Applicant and observed the following: Per facility sketch, facility is a one story residence with 4 client bedrooms, two bathrooms, 1 staff room, an office space, and common areas. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility's hot water temperatures for all sinks were within Title 22 Regulations of 105F to 120F. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Toxins were observed to be stored in facility's laundry room and inaccessible to clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. All client rooms were furnished with a bed, lamp, dresser, and chair. Facility has sufficient items for cooking and eating. Per Applicant, Staff and Client files, and Client medications will be located in the locked office. Facility has indoor/outdoor areas for visiting and activities. Facility's fire extinguisher is newly purchased and was observed to be fully charged. Facility's combination smoke and carbon monoxide detectors were tested and operational. LPA confirmed that contents of the facility's First Aid Kit were sufficient. During walkthrough, LPA and Applicant discussed the following items:
  • Night Stands - Applicant to purchase night stands for each client room
  • Licensing Posters - Emergency Plans/Contact information, CCLD Complaints, Ombudsman, Visitor Policy
  • Emergency Lighting (Applicant to purchase flashlights and/or install emergency lighting)
  • Accessible Fireplace in the Dining Room (Applicant to purchase items to make fireplace inaccessible to clients)
  • Protective Mattress Pads - Applicant understands that mattress pads should be available on-site for client use if requested
  • Staffing, facility emergency disaster plan, and Guardian background clearance and associations
Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAN JOSE CARE HOME II
FACILITY NUMBER: 486804272
VISIT DATE: 10/18/2024
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Continued from LIC809

Applicant to submit proof that nightstands, posters, lighting, fireplace, and linens are completed prior to having clients move into the facility. Proof to be submitted to Community Care Licensing (CCL) by 10/28/2024. Component III was reviewed with Applicant.

No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Adult Residential Facility. LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.

Exit interview conducted. Copy of report discussed and provided to Applicant. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC809 (FAS) - (06/04)
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