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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202886
Report Date: 03/06/2023
Date Signed: 03/06/2023 10:32:50 AM

Document Has Been Signed on 03/06/2023 10:32 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:MILLHAVEN HOMEFACILITY NUMBER:
435202886
ADMINISTRATOR:LIGUTOM, FLAMINGOFACILITY TYPE:
735
ADDRESS:107 MILLHAVEN PLACETELEPHONE:
(408) 515-7345
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 0DATE:
03/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Flamingo LigutomTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) David Marrufo conducted a Prelicensing visit and met with Administrator Flamingo Ligutom.

During visit, LPA Marrufo toured the inside and outside of the facility. No residents were observed during visit. LPA Marrufo toured the kitchen area. A first aid kit was observed as well as a fire extinguisher. LPA Marrufo observed the kitchen refrigerator and other food storage areas. 4 out of 4 resident bedrooms were observed. Each bedroom had a bed with bedding, available clothing storage, and functioning lighting. LPA tested 1 out of 1 carbon monoxide detectors and 6 out of 6 smoke detectors, all of which functioned properly when tested. The outdoor exits were observed and the exits were clear of obstructions.

LPA Marrufo reviewed Component III with Administrator Flamingo Ligutom.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Flamingo Ligutom and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2023
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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