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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202564
Report Date: 04/04/2023
Date Signed: 04/04/2023 05:02:53 PM


Document Has Been Signed on 04/04/2023 05:02 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:CHERISH SENIOR CARE HOMEFACILITY NUMBER:
435202564
ADMINISTRATOR:PANGALIMAN, LEILANIE TFACILITY TYPE:
740
ADDRESS:2858 ROSS AVENUETELEPHONE:
(408) 266-0507
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 6DATE:
04/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Leilanie PangalimanTIME COMPLETED:
04:32 PM
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Licensing Program Analysts (LPAs) Steve Chang and Ravi Patel conducted an unannounced annual inspection visit, and met with Administrator (ADM) Leilanie Pangaliman.

LPAs checked 5 resident record files (R1 - R5) and 5 staff record files (S1 - S5). 6 residents (R1 - R6) and 1 staff (S3) were interviewed.

LPAs toured the facility inside out with ADM. Facility license, Administrator Certificate, Personal Rights posters were observed posted at the facility. Living room, kitchen, dinning room and two restrooms were inspected. Six single resident bedrooms, and laundry room were inspected. Two staff live-in rooms are in facility.

Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 110 degree F in facility.

Fire extinguisher was serviced on 02/24/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
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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