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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200855
Report Date: 01/06/2023
Date Signed: 01/06/2023 11:44:32 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/06/2023 11:44 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:PRINCESS CAREFACILITY NUMBER:
435200855
ADMINISTRATOR:MORALES, JAMES T.FACILITY TYPE:
740
ADDRESS:1525 ILIKAI AVENUETELEPHONE:
(408) 266-9205
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 0DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Facility Manager Randi CabreraTIME COMPLETED:
11:45 AM
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On 1/6/2023 at 10:40am, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual inspection today and met with Facility Manager (FM) Randi Cabrera. FM stated there is no client in the facility. FM stated the facility is non operational. No COVID-19 signs were observed in the facility.

LPA Rai toured the facility and inspected the living room, dining room, kitchen, 2 restrooms, and 5 bedrooms.

The facility is in non operational status.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Facility Manager (FM) Randi Cabrera and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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