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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202882
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:37:01 PM

Document Has Been Signed on 04/18/2024 03:37 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BROOKWOOD TERRACE HOME ONEFACILITY NUMBER:
435202882
ADMINISTRATOR/
DIRECTOR:		TEODORO, ARIELLEFACILITY TYPE:
740
ADDRESS:319 S. 23RD STREETTELEPHONE:
(408) 883-2000
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6CENSUS: 5DATE:
04/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Staff Member Romeo TambuaTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On April 18, 2024, Licensing Program Analysts (LPAs) Manuel Monter and Simi Rai conducted an unannounced Case Management visit and met with Staff Member Romeo Tambua and explained that the purpose of the visit was to hand deliver a letter of exclusion for staff S1.

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

This report was reviewed with Administrator (ADM) Arielle Teodoro, via phone call. ADM stated staff member Romeo Tambua could sign on her behalf. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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