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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202629
Report Date: 06/01/2023
Date Signed: 06/01/2023 06:13:48 PM


Document Has Been Signed on 06/01/2023 06:13 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:
06/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Administrator (ADM) Michelle PagkalinawanTIME COMPLETED:
06:15 PM
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Licensing Program Analysts (LPAs) Simi Rai and Ravi Patel conducted a case management visit while facility was being inspected for pre-licensing visit for Lotus of Cupertino Care Home. LPAs met with Administrator (ADM) Michelle Pagkalinawan.

During today's visit,these are the deficiencies observed during the pre-licensing visit. Citations will be given at later.

The following deficiencies will be cited under the following regulations:

87303 Maintenance and Operation, 87307 Personal Accommodations and Services and, 87705 Care of Persons with Dementia, and 87309 Storage Space

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: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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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