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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202392
Report Date: 04/24/2024
Date Signed: 04/24/2024 04:01:53 PM


Document Has Been Signed on 04/24/2024 04:01 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: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: DATE:
04/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Administrator Philomena AgbontaenTIME COMPLETED:
04:05 PM
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Licensing Program Analyst Manuel Monter conducted an unannounced Case Management visit, to verify the change of capacity. LPA met with Administrator Philomena Agbontaen and explained the purpose of the visit.
On April 24, 2024, Licensing Program Analyst Manuel Monter conducted a CM inspection to verify the change of capacity from 6 to 7 Non Ambulatory. According to Licensee/ADM, the facility did not have major construction; however they have an additional room herein they can convert to a resident's room.

Fire clearance was granted on June 15, 2023, for an additional capacity in bedroom #6.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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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