<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294284
Report Date: 08/09/2022
Date Signed: 08/09/2022 12:09:47 PM

Document Has Been Signed on 08/09/2022 12:09 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:ST. MARY'S RESIDENTIAL CARE HOME IIFACILITY NUMBER:
435294284
ADMINISTRATOR:ARIMAS, MARILUZ & MERLINOFACILITY TYPE:
740
ADDRESS:1265 SOCORRO AVENUETELEPHONE:
(408) 390-4931
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY: 6CENSUS: 5DATE:
08/09/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Joseph Bryan CastanedaTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/09/2022, Licensing Program Analyst (LPA) Mandeep Kaur conducted an unannounced Case Management -Legal/Non-compliance inspection and met with Facility Staff, Joseph Bryan Castaneda.

The purpose of the visit is to ensure that facility is adhering to the Compliance Plan submitted to Community
Care Licensing (CCL) after a Non-Compliance Conference held on 09/11/2020.

Upon entry, LPA was greeted at the door by the Facility Staff. Facility has a screening sheet, thermometer, and hand sanitizer available at entry. LPA toured the facility to include the common areas, resident rooms, and backyard. The facility was in a comfortable temperature and observed to be clean and maintained. All of the staff members were observed wearing a face mask. Medication cabinet observed to be locked in the kitchen.

Administrator Mariluz Arimas was not able to join during the visit. Over the Phone, LPA discussed with the Administrator, Mariluz Arimas, the facility's plan to update resident's care plan when resident's are being discharged from the hospital or observed to have a change of health condition. LPA reviewed facility staffing schedule and annual training. LPA reviewed the residents' meets and needs services.

No deficiency cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with facility staff Joseph Bryan Castaneda as verbally authorized by administrator, Mariluz Arimas and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1