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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200359
Report Date: 12/07/2023
Date Signed: 12/19/2023 11:55:43 AM


Document Has Been Signed on 12/19/2023 11:55 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
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:
12/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:13 PM
MET WITH:Camille MoralesTIME COMPLETED:
05:53 PM
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On 12/7/2023, at 5:13PM, Licensing Program Analysts(LPAs) Steve Chang and Mita Partoza conducted an unannounced visit and met with Camille Morales (CM).


On 11/21/2023, the Department received a facility closure letter from the licensee with date effective 11/20/23.

LPAs toured inspected the facility with CM. The facility has ceased operation since 10/18/2012 and have not accepted any resident. LPAs observed that a family resides in the facility. LPAs observed that no residents are in the facility.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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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