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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202629
Report Date: 01/30/2023
Date Signed: 01/30/2023 01:55:47 PM


Document Has Been Signed on 01/30/2023 01:55 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: 9DATE:
01/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Michelle Pagkalinawan, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Simi Rai and Manuel Monter conducted a Case Management related to LPA Rai's visit on 11/2/2022 when the facility was using the laundry room as a staff living quarters and an update on the lease agreement. Upon arrival LPA Rai was greeted at the facility by Michelle Pagkalinawan, Administrator.

On today's case management visit, LPAs conducted two staff interviews (S1 & S2) and observed the facility laundry room. The garage is converted into a laundry room and partitioned to the right side as a staff room. A kitchen/bathroom are located on the left side of the room. Upon entering the staff room, LPAs observed a full-size bed rails without mattress, a night stand, and other personal items. Administrator stated the staff are not currently sleeping or using the room. At this time, staff lives outside of the facility and staff will remove items from the room. Administrator understands the kitchen/bathroom in the laundry room will not be used by staff to use or cook food. Going forward, Administrator will use the staff room as a storage room. Administrator will submit a facility physical sketch with the updated use of the room.

On 1/23/2023, LPA received a call from Licensee to follow up on the status of the lease agreement. Licensee was informed to provide care and supervision to residents until all residents have been moved or placed in appropriate RCFE facilities. Administrator notified LPA about currently working with landlord to create a smooth transition and the landlord will take over the existing facility. LPA received a copy of the residents' LIC 601 Identification and Emergency Information forms and updated Physician's Report. LPA advised facility to assist resident and their families on finding a suitable facility for their resident.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Michelle Pagkalinawan and a copy of the report was provided
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
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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