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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201105
Report Date: 07/17/2024
Date Signed: 07/17/2024 04:00:57 PM

Document Has Been Signed on 07/17/2024 04:00 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:HILLSDALE HOMEFACILITY NUMBER:
435201105
ADMINISTRATOR/
DIRECTOR:		JOHN TANAKAFACILITY TYPE:
735
ADDRESS:318 LOS PINOS WAYTELEPHONE:
(408) 599-9597
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6CENSUS: 4DATE:
07/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:John TanakaTIME VISIT/
INSPECTION COMPLETED:
03:36 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit, and met with Administrator (ADM) John Tanaka .

The purpose of today's visit is to deliver a civil penalty assessment of $500 penalty for fingerprint clearance. On 6/26/2024, a type A citation with Title 22 section 80019(e) for fingerprint clearance was issued. A civil penalty was not assessed during the visit.

Exit interview was conducted with ADM. Civil penalty assessment form and this report were provided to ADM for signature. A copy of this report and civil penalty assessment form were provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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