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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202142
Report Date: 11/03/2023
Date Signed: 11/03/2023 01:52:35 PM

Document Has Been Signed on 11/03/2023 01:52 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:ANNIE'S CARE HOME #2FACILITY NUMBER:
435202142
ADMINISTRATOR:ANITA DELA CRUZFACILITY TYPE:
735
ADDRESS:954 IDLEWOOD DR.TELEPHONE:
(408) 281-7589
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 3DATE:
11/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Anita Dela CruzTIME COMPLETED:
02:00 PM
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Licensing Program Analyst Manuel Monter conducted an unannounced case management regarding an incident report that was submitted on November 2, 2023. LPA met with (ADM) administrator Anita Dela Cruz & explained the purpose of the visit.

On November 2, 2023, the department received a death report stating resident R1 was unresponsive when he/she arrived from the day program. R1 was taken to the emergency room. R1 subsequently passed away at the hospital. R1's death is unknown at this time. ADM will provide death certificate once it becomes available. San Andreas regional center and R1's responsible party is aware.

LPA interviewed S1, S2 and ADM regrading the incident that occurred on 11/01/2023.

LPA requested the following documents/ video footage from the administrator:
Ring-Video footage of the incident, R1's physicians report, R1's appraisal needs and services plan, R1's pre-appraisal, R1's IPP, facility progress notes regarding R1. Centrally stored Medication, MAR, BM Log, communication log with the day program, R1's emergency form. PRN Log. & seizure log.

No deficiencies cited during todays visit. Report was reviewed with ADM Anita Dela Cruz and a copy was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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