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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202238
Report Date: 12/16/2022
Date Signed: 12/16/2022 01:52:33 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/16/2022 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:FANTASIA CARE HOMEFACILITY NUMBER:
435202238
ADMINISTRATOR:FERDINAND/MERLITA PATIOFACILITY TYPE:
735
ADDRESS:98 CHERRY BLOSSOM DR.TELEPHONE:
(408) 281-1992
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 0DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:TIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced Annual inspection visit to facility today. LPA was unable to enter facility because nobody was home.

LPA was able to contact the Administrator, Ferdinand Patio via telephone who states the facility has not admitted any clients since license approval due to pending San Andreas Regional center (SARC) vendorization approval. Administrator was unable to meet LPA at the facility.

At 1:50PM, LPA left the facility.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
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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