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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200855
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:30:53 PM


Document Has Been Signed on 11/30/2023 02:30 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
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:
11/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Facility Manager, Randi Cabrera. TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management visit to conduct a facility closure tour. LPAs met with Facility Manager, Randi Cabrera.

LPA toured the facility inside and outside. LPAs did not observe any residents to be present at the facility. The facility was non-operational. The facility closure plan was submitted to the Regional Office on 11/20/2023.

The Licensee submitted original license to the Regional Office.

No deficiencies were cited at this time as per California Code of Regulations Title 22. As of 11/20/2023, the facility license is no longer valid. LPA explained the closure process to Facility Manager.

This report was reviewed with Facility Manager, 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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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