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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200359
Report Date: 10/22/2021
Date Signed: 10/22/2021 04:42:55 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PRINCESS CARE HOME #5FACILITY NUMBER:
435200359
ADMINISTRATOR:MORALES, JUDITH P.FACILITY TYPE:
740
ADDRESS:5454 RUDY DRIVETELEPHONE:
(408) 264-6147
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 0DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Jasen MorlesTIME COMPLETED:
03:50 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
At 2:35PM, Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection. Upon arrival, LPA pressed the door bell, but nobody answered the door. LPA wait for 5 minutes, then Call Facility manager Randi Cabrera (FM). FM stated the facility does not operate for more than 6 years, FM stated FM will try to find someone to open the door.

At 3:10PM, Jasen Morles (JM) arrived at facility, and opened the door for LPA.

LPA toured the facility with JM. There are 7 bedrooms, 4 restrooms, Living room, family room, dinning area and kitchen. No COVID poster was observed in the facility. No central screening station was observed.

The facility is not in operational status. Actually, one family lives in the house.

JM stated the facility does not operate for more than 6 years. LPA spoke to JM to close the facility, JM stated JM will discuss with licensee, JM's mother about this.

JM stated JM will let LPA know after JM discussed with licensee.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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