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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202629
Report Date: 05/17/2023
Date Signed: 05/17/2023 12:30:49 PM


Document Has Been Signed on 05/17/2023 12:30 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: 8DATE:
05/17/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator (ADM) Michelle PagkalinawanTIME COMPLETED:
12:30 PM
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Regional Manager (RM) Vivien Helbling, Licensing Program Manager (LPM) Romeo Manzano, Licensing Program Analyst (LPA) Simi Rai conducted an announced informal meeting with ADM and President of Corporation (Blended Family Care Home LLC), Michelle Pagkalinawan to follow up from the visit conducted on May 11, 2023. The goal of meeting is to mitigate and solution the issues of the physical plant to be in compliance and ensure the health and safety of the residents in care.

The facility will submit the plan of Operations of the facility to ensure the less inconvenience for the residents that are currently living in the facility, maintenance/repair of the facility, staffing and financial operation of the facility.

ADM was informed that the Department will increase monitoring of the facility. ADM was advised to work with the Ombudsman, County of Santa Clara Environmental Health and City of Cupertino Building Code Department, and other applicable agencies.

Report was reviewed with facility ADM. A copy of this report was signed and provided by Administrator Michelle Pagkalinawan during today's informal meeting visit.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
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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