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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202629
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:31:36 PM


Document Has Been Signed on 11/09/2022 02:31 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:BLENDED FAMILY CARE HOMEFACILITY NUMBER:
435202629
ADMINISTRATOR:PAGKALINAWAN, MICHELLEFACILITY TYPE:
740
ADDRESS:10366 MILLER AVENUETELEPHONE:
(408) 802-6410
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:12CENSUS: DATE:
11/09/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:TIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Simi Rai met with Licensee in the office. The purpose of this visit was to amend the citation under CCR 87355(e)(1) issued on 11/2/2022 to clarify the individual was fingerprint cleared but did not have receive a criminal record exemption clearance.

LPA advised Licensee to contact CDSS Guardian to follow up on the status and inform Licensing once the exemption clearance has been received. Until the Licensee does not receive the clearance, the individual is not allowed to be working, volunteering or residing in the facility.

Citation issued under 87465(h)(2) has been cleared as of 11/9/2022. A copy of POC clearance provided during office visit.

No citation issued at this time.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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