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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708102
Report Date: 02/23/2022
Date Signed: 02/23/2022 03:48:57 PM

Document Has Been Signed on 02/23/2022 03:48 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MERTZ CARE HOMEFACILITY NUMBER:
430708102
ADMINISTRATOR:MERTZ, ELVIRAFACILITY TYPE:
740
ADDRESS:2715 MCLAUGHLIN AVENUETELEPHONE:
(408) 483-2748
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 3DATE:
02/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:JIMENEZ, Y. ROGELINETIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) arrived unannounced to conduct a required 1 year inspection and met with direct staff, Chelsea Plaza and Administrator Rogeline Jimenez.

LPA toured the facility inside and outside to include the kitchen, dining room, living room, resident rooms, bathrooms, garage, and backyard.

Facility's anniversary month is in August. On 08/31/2021, facility had completed their annual required inspection. LPA had inputted the wrong address and meant to inspect Mertz Care Home III #435200786.

No deficiencies were cited during visit per California Code of Regulations, Title 22.

This report was reviewed with Administrator Rogeline Jimenez and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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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