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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202238
Report Date: 12/26/2024
Date Signed: 12/26/2024 04:58:58 PM

Document Has Been Signed on 12/26/2024 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:FANTASIA CARE HOMEFACILITY NUMBER:
435202238
ADMINISTRATOR/
DIRECTOR:		FERDINAND/MERLITA PATIOFACILITY TYPE:
735
ADDRESS:98 CHERRY BLOSSOM DR.TELEPHONE:
(408) 281-1992
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 0DATE:
12/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Ferdinand PatioTIME VISIT/
INSPECTION COMPLETED:
04:31 PM
NARRATIVE
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Licensing Program Analyst(LPA) Steve Chang conducted an unannounced case management visit and met with licensee Ferdinand Patio.

On 12/16/2024, The Department conducted an unannounced annual inspection at the facility. The facility was found under construction. The Department did not receive any notice that the facility is going to conduct new construction/alteration.

LPA interviewed Licensee. Licensee stated the facility is converting two bedrooms into 3 bedrooms. Licensee stated before the facility had 4 bedrooms, and the facility will have 5 bedrooms. Licensee stated after the construction, the facility will apply for a new fire clearance and submit to CCL office.

Deficiency noted for the facility did not notify CCL office prior to conduct alteration/construction of the existing building. LPA request the facility to provide the new sketch of the facility.

Citation was issued today. See LIC809-D for detail.

Exit interview was conducted with Licensee. The report was provided for review and signature. A copy of the report was provided to Licensee.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/26/2024 04:58 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 12/26/2024 at 03:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: FANTASIA CARE HOME
FACILITY NUMBER: 435202238

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2024
Section Cited
CCR
80086(a)

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80086 Alteration to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
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Licensee stated to send a plan of correction by the POC due date to ensure the facility notify CCL office prior to conduct any alteration/conduction.
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Based on observation and record review, the licensee did not comply with the section cited above in that the during LPA's inspection visit, LPA observed two bedrooms were converted 3 bedrooms and still under construction. The facility did not notify CCL office that the facility to convert two bedrooms into 3 bedrooms. which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
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