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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202886
Report Date: 03/28/2024
Date Signed: 03/28/2024 10:01:34 PM

Document Has Been Signed on 03/28/2024 10:01 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
Lookup Error,
, CA
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:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Flamingo LigutomTIME COMPLETED:
12:15 PM
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On 3/28/24 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Flamingo Ligutom. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including a random sample of resident rooms, common areas & kitchen area. The indoor and outdoor passageways were free of obstruction. Facility doesn't have any residents in care. Hot water was tested in the bathrooms and the temperature was 109 deg F. Carbon monoxide/smoke detectors, and fire extinguisher were present throughout the facility. Resident bedrooms and bathrooms were observed to be in good repair. Bathrooms are equipped non-skid floors. The facility is observed to be clean and well maintained.

Facility is still waiting to be vendorized by San Andreas Regional Center.

No deficiencies cited today. This report was reviewed a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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