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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202142
Report Date: 01/31/2024
Date Signed: 01/31/2024 09:32:05 AM

Document Has Been Signed on 01/31/2024 09:32 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: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:
01/31/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Administrator Anita Dela CruzTIME COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to conclude the case management visit conducted on 11/03/2023. LPA Monter met with Administrator (ADM) Anita Dela Cruz and stated the purpose of the visit. LPA Monter observed 0 residents and 2 staff member at the facility. 3 Out of the 3 residents were at the day program during LPA's visit.

On November 2, 2023, the department received a death report and incident report stating resident R1 was unresponsive when he/she arrived from the day program on November 1, 2023 at approximately 1:52pm. Day program staff contacted 911 and R1 was taken to the emergency room. R1 subsequently passed away at the hospital.

Based on a review of R1’s physicians report, dated September 29, 2023, R1 is a resident with developmental disabilities and underlying health conditions. Based on review of R1’s Death Certificate, R1’s death was due to natural causes and there were no other significant conditions contributing to R1’s death.

No deficiencies were cited at this time as per California Code of Regulations, Title 22. This report was reviewed with Administrator Anita Dela Cruz and a copy of this report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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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