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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202392
Report Date: 06/29/2023
Date Signed: 06/29/2023 11:40:59 AM

Document Has Been Signed on 06/29/2023 11:40 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:EVONNE'S RESIDENTIAL CARE HOME #1FACILITY NUMBER:
435202392
ADMINISTRATOR:PHILOMENA AGBONTAENFACILITY TYPE:
740
ADDRESS:2719 PENITENCIA CREEK RD.TELEPHONE:
(408) 661-5746
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 5DATE:
06/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Philomena AgbontaenTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Philomena Agbontaen. The purpose of the visit was to observe the new bedroom that was added to the facility bed capacity.

During visit, LPA Marrufo observed the new bedroom. The bedroom had working lighting, a smoke detector, functioning window blinds, and electrical outlets and cable connections on the walls.

LPA Marrufo toured the other 5 resident bedrooms and observed them to have beds, lighting, and smoke detectors.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Philomena Agbontaen and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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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