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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708724
Report Date: 11/10/2022
Date Signed: 11/10/2022 10:39:13 AM


Document Has Been Signed on 11/10/2022 10:39 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:LINCOLN & PINE, WILLOW GLENFACILITY NUMBER:
430708724
ADMINISTRATOR:LIGAYA SEMANAFACILITY TYPE:
740
ADDRESS:1710 LINCOLN AVENUETELEPHONE:
(408) 265-6520
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 5DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
10:45 AM
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
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Erene Bautista.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed there to be a perishable food supply of 2 days and a non-perishable food supply of 7 days. LPA Marrufo observed a PPE supply of 30 days. LPA Marrufo observed a visitor screening area at the entrance. LPA Marrufo toured the outside area of the facility and found the exits to be free of obstructions.

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

This report was reviewed with Administrator Erene Bautista and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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