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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202424
Report Date: 07/16/2021
Date Signed: 07/16/2021 04:02:39 PM

Document Has Been Signed on 07/16/2021 04:02 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,
, CA
FACILITY NAME:CASA LAURELFACILITY NUMBER:
435202424
ADMINISTRATOR:SOL SAMONTEFACILITY TYPE:
740
ADDRESS:680 NORTH 18TH ST.TELEPHONE:
(408) 287-4541
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 6CENSUS: 4DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Manuel and Illuminada YapTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Manuel and Illuminada Yap.

During visit, LPA Marrufo toured the facility. LPA Marrufo observed there to be a visitor screening station at the entrance with screening logs for temperature and symptoms. LPA Marrufo observed two out of two bathrooms to have available soap and paper towels for residents. Hand washing signs were posted in the bathrooms and COVID-19 related posters were posted throughout the facility hallways. LPA Marrufo observed the PPE supplies and observed there to be a 30 day supply. LPA Marrufo observed the facility food supply and observed there to be a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days.

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

LPA Marrufo requests that the following documents be updated and copies sent to CCL:

LIC500 Personnel Report
LIC308 Designation of Administrative Responsibility
LIC610 Emergency Disaster Plan

This report was reviewed with Illuminada Yap and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
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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