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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804272
Report Date: 09/16/2025
Date Signed: 09/16/2025 12:45:02 PM

Document Has Been Signed on 09/16/2025 12:45 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
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: DATE:
09/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Corazon Lalic - licensee/adminstrator TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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At approximately 9:40 AM, Licensing Program Analyst (LPA) tevenson arrived announced to conduct a required 1-year annual Inspection, today's inspection is the first since licensing and LPA met with licensee/administrator Corazon "Cora" Lalic. Upon arrival, LPA was informed that there are currently two (2) clients in care both of which are away at day program. Facility has a total capacity of 4 clients, where 2 can be ambulatory, 1 can be non-ambulatory, and 1 can be bedridden.

LPA advised licensee of the difficulty seeing the address numbers on the street, as well as, the silver numbers on white paint nearer to the front door and licensee was advised to have fresh numbers painted at the curb to make it easier for emergency personnel to see the home.

LPA conducted a walk-though of facility with licensee 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, in addition LPA observed go bag backpacks for each client in care. Facility's hot water temperatures for all sinks were adjusted in compliance with Title 22 Regulations of 105F to 120F. There was an appropriate supply of cleaning products, linens, hygiene products available for clients. Toxins were observed to be stored in facility's laundry room and inaccessible to clients. Bathrooms were equipped with anti-slip mats and grab bars. The facility has hardwired combination smoke and carbon monoxide detectors that were tested and found operational. All client rooms were furnished with a bed, lamp, dresser, and chair per title 22 regulations.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/16/2025
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Continued from LIC809
A large fire extinguisher was last inspected July 2025 and observed to be fully charged.

The facilities last emergency disaster drill was performed July of 2025 and licensee was advised of the requirement to have quarterly disaster drills.

LPA observed the toilet seat for clients in care to be a standard size mounted to an elongated toilet and licensee was advised to attain an elongated seat to bolt to the elongated toilet to increase safety for clients in care. LPA noted a very large backyard, that lacked a shaded space for clients in care and a technical violation was issued to install a shade space for eating/meeting outside.

At approximately 11:45 AM medication storage and record keeping was observed to be centrally locked and organized per regulation.

Licensee attained today:
1)Updated Surety Bond
2)Updated LIC400 Affidavit Regarding Client Cash Resources

Licensee to send Community Care Licensing (CCL) the following documents by 10/15/2025
1)LIC500 Personal Roster
2)LIC9020 Client Roster
3)Updated LIC610D Emergency Disaster Plan

Technical violations and advisories are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code.

No Deficiencies are cited today.


This report was reviewed with licensee Lilac "Cora" Corazon and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC809 (FAS) - (06/04)
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