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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708102
Report Date: 04/29/2022
Date Signed: 04/29/2022 03:05:07 PM

Document Has Been Signed on 04/29/2022 03:05 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:
04/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Chelsea PlazaTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Other visit and met with Chelsea Plaza.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed there to be a visitor screening area. LPA Marrufo observed the facility had a PPE supply of at least 30 days. LPA Marrufo observed there to be a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days.

LPA Marrufo observed the outside exits were clear of obstructions.


No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Chelsea Plaza and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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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