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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202942
Report Date: 10/28/2024
Date Signed: 10/28/2024 02:11:18 PM

Document Has Been Signed on 10/28/2024 02:11 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:GRETCHEN RESIDENTIAL CARE HOME, INC.FACILITY NUMBER:
435202942
ADMINISTRATOR/
DIRECTOR:		ESTOESTA, DAISYFACILITY TYPE:
740
ADDRESS:1716 BERRYWOOD DRIVETELEPHONE:
(408) 930-7565
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 4DATE:
10/28/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Daisy Estoesta, Administrator/ApplicantTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Component II completion: Successful

Facility Type: Residential Care Facility for the Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 4
COMP II Participants: Daisy Estoesta, Administrator/Applicant
Interview Method: Telephone interview

On October 28, 2024 at 1:00 PM, Applicant/Administrator participated in COMP II. Identification of the Applicant/Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant/Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program.
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicant. Report sent via email and informed to return sign copy to CAB by end business day.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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