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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200996
Report Date: 02/14/2024
Date Signed: 02/14/2024 04:58:44 PM


Document Has Been Signed on 02/14/2024 04:58 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 LODGEFACILITY NUMBER:
435200996
ADMINISTRATOR:MORALES, JAMESFACILITY TYPE:
740
ADDRESS:552 WEST HACIENDA AVENUETELEPHONE:
(408) 379-9331
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:30CENSUS: 20DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rica Uy and Randi CabreraTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Mita Partoza conducted an unannounced annual inspection at the facility. LPA met with Facility Manager Rica Uy (FM) and Randi Cabrera facility administrator.

Current facility census count 20 resident. 1 out 20 is undergoing rehabilitation.

During the visit, LPA toured the facility with the facility manager (FM) Rica Uy and Administrator (ADM) Randi Cabrera, the tour includes the living room, dining room, kitchen, 14 resident bedrooms. The 2nd floor area dedicated for staff and the outdoor perimeter, the parking area and the maintenance area.

The facility has 16 bedrooms some shared and some single occupancy. The 9 bathrooms on the ground floor are either in between 2 rooms and some are not shared. The facility has an office, a staff break room and a 2nd floor staff area for staff who lives in the facility. The 2nd floor has 4 bedroom and a kitchenette used by staff. The door leading to the staff 2nd floor area is kept locked.

The laundry room doubles as a cleaning supplies and toxic material storage and is kept locked at all times. The dry food storage room stores sufficient supply for 7 days non-perishable food for resident and staff and 2 days of perishable food supply.

Due to time constraint LPA will continue with the annual required inspection at a later date.

No deficiencies were cited per California Code of Regulations, Title 22 during today's visit. This report was reviewed with administrator Randi Cabrera.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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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