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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200359
Report Date: 10/25/2022
Date Signed: 10/25/2022 04:24:34 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/25/2022 04:24 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, 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:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Jansen MoralesTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met Jansen Morales (JM) and his wife Camille Morales (CM). JM stated the facility is non operational. CM's Mom and Dad were observed at the facility. CM stated CM's Mom and Dad visit the family for two weeks.

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 has not operated for more than 7 years. LPA spoke to JM to close the facility, JM stated JM will discuss with licensee about this.

No citation was issued today. Exit interview was conducted with JM. This report was provided to JM for signature. A copy of this report was provided to JM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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