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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202912
Report Date: 08/07/2023
Date Signed: 08/07/2023 10:16:02 AM

Document Has Been Signed on 08/07/2023 10:16 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:MARY'S HOUSE #2FACILITY NUMBER:
435202912
ADMINISTRATOR:MENDOZA, ROSANAFACILITY TYPE:
740
ADDRESS:324 BURNING TREE DRTELEPHONE:
(408) 439-1703
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6CENSUS: 0DATE:
08/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rosana MendozaTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) David Marrufo conducted a Case Management visit and met with Administrator Rosana Mendoza. The purpose of the visit was to follow up on the previous pre-licensing visit.

During visit, LPA Marrufo observed 2 out of 2 bathrooms had grab bars in the showers. LPA Marrufo observed a locked key cabinet that had spare keys inside. LPA Marrufo observed an updated LIC610E Emergency Evacuation Plan.

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

This report was reviewed with Administrator Rosana Mendoza and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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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