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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202643
Report Date: 10/17/2024
Date Signed: 10/17/2024 05:06:22 PM


Document Has Been Signed on 10/17/2024 05:06 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:AMY'S RESIDENTIAL CARE, INC.FACILITY NUMBER:
435202643
ADMINISTRATOR:SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:671 N WHITE RDTELEPHONE:
(408) 898-8784
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 5DATE:
10/17/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Amarjeet MannTIME COMPLETED:
04:22 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - other visit to collect more information and met with Administrator (ADM) Amarjeet Mann.

The purpose of today's visit is to clarify some questions regarding resident R1 and collect more information regrading an incident occurred before.

LPA interviewed staff S1, House Manage (HM), and Administrator (ADM) Amarjeet Mann.

No citation noted today. Exit interview was conducted with ADM.

The report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
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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