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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202392
Report Date:
12/04/2024
Date Signed:
12/04/2024 05:29:08 PM
Document Has Been Signed on
12/04/2024 05:29 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 #1
FACILITY NUMBER:
435202392
ADMINISTRATOR/
DIRECTOR:
PHILOMENA AGBONTAEN
FACILITY TYPE:
740
ADDRESS:
2719 PENITENCIA CREEK RD.
TELEPHONE:
(408) 661-5746
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95132
CAPACITY:
7
TOTAL ENROLLED CHILDREN:
0
CENSUS:
7
DATE:
12/04/2024
TYPE OF VISIT:
Collateral
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
04:35 PM
MET WITH:
Philomena Agbontaen
TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 12/4/24 LPA's David Marrufo and Santino Fortes conducted an unannounced facility visit and met with Philomena Agbontaen to conduct a collateral visit to deliver a complaint for Evonne's Residential Care Home #3.
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 this report was provided
Jackie Jin
TELEPHONE:
(714) 319-3786
Santino Fortes
TELEPHONE:
(818) 378-8120
DATE:
12/04/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/04/2024
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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