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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201653
Report Date: 01/29/2025
Date Signed: 01/29/2025 11:44:48 AM

Document Has Been Signed on 01/29/2025 11:44 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LSA - HOME #1FACILITY NUMBER:
435201653
ADMINISTRATOR/
DIRECTOR:		CHERYLL LAGUNILLAFACILITY TYPE:
740
ADDRESS:810 AGNEW RDTELEPHONE:
(408) 988-8901
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 6CENSUS: 5DATE:
01/29/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Justin Williams, Staff Training & Development Coordinator TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On January 29, 2025 at 11:00 AM, Licensing Program Analysts (LPAs) Kenneth Madrigal and Simi Rai arrived at the facility unannounced to conduct a case management – other visit. LPAs met with Justin Williams, Staff Training & Development Coordinator . LPAs observed two staff members and three residents at the facility. Two out of the five residents were out of the facility during the visit.

The purpose of the visit is to hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical as a staff in the facility. The letter was handed to the Staff Training & Development Coordinator. The Staff Training & Development Coordinator states S1 was never hired, does not work for the facility, and is not in their Human Resources (HR) system.

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

This report was reviewed with Staff Training & Development Coordinator, Justin Williams and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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