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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202629
Report Date: 02/24/2023
Date Signed: 03/06/2023 03:09:38 PM


Document Has Been Signed on 03/06/2023 03:09 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:
4088026410
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:12CENSUS: 9DATE:
02/24/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Michelle PagkalinawanTIME COMPLETED:
10:33 AM
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At 10:00 am, Licensing Program Manager (LPM) Romeo Manzano and Licensing Program Analyst (LPA) Manuel Monter conducted a teams meeting with Administrator (ADM) Michelle Pagkalinawan and the facility property landlord, Ms. Gilda Tayo

The purpose of the meeting is to find out the change of ownership plan and the status of their lease agreement. Ms. Tayo confirmed new lease agreement with Blended Family Care Home. Ms. Tayo stated that lease agreement will be terminated after new RCFE license has been obtained. Ms. Tayo stated she had already applied for new application to Centralized Application Bureau (CAB) in the month of January 2023, under the facility name of Lotus of Cupertino Care Home.

ADM confirmed with the terms and conditions of their lease agreement. ADM to send a copy of new lease agreement and board resolution before the end of today. ADM and Ms. Tayo stated that they have plans to have a meeting with the residents and their families and introduce themselves and inform them of the transition. LPA also advised Ms Tayo to evaluate and assess the residents. LPM also talked about residents personal rights; their rights to choose to receive continued care with the incoming licensee, if they choose to continue.

LPM suggested Ms.Tayo to include hospice waiver and bedridden clearance request as part of their RCFE application as one of the current resident at this facility is under hospice care. Ms. Tayo confirmed that the garage will be utilized as a laundry room but also advised to obtain building permits and fire clearance if changes or alterations are made to the existing building.

LPM also informed ADM that when she has residents move, to notify the department.

No deficiencies cited during this office meeting.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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