<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202629
Report Date: 07/11/2023
Date Signed: 07/11/2023 09:32:42 AM


Document Has Been Signed on 07/11/2023 09:32 AM - 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: 0DATE:
07/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee/ Administrator Michelle PagkalinawanTIME COMPLETED:
09:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Simi Rai and Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced Case Management visit to conduct a facility closure tour. LPAs met with Licensee/ Administrator Michelle Pagkalinawan.

LPA and LPM toured the facility inside and out, including 8 out of 8 resident rooms. LPAs did not observe any residents to be present at the facility. During visit, LPA obtained the original facility license. Licensee confirmed that all residents had been moved out of the facility as of 7/1/2023, and had previously submitted facility closure plan to the regional office on 6/6/2023. All previous residents were confirmed to have been relocated. Operation at the facility has ceased effective 07/01/2023.

During tour, LPA Rai observed the second floor and ADM stated 2 staff members were residing in two rooms and they have agreement with landlord in place. The Department does not have jurisdiction in staff and landlord agreement as long as resident do not live in the building. LPA and LPM observed the facility undergoing renovations.

No deficiencies were cited at this time as per California Code of Regulations Title 22. As of 07/01/2023, the facility license is no longer valid. LPA explained the closure process to licensee and provided licensee with a copy of this report.

This report was reviewed with Licensee/ 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: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1