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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202886
Report Date: 03/11/2025
Date Signed: 03/11/2025 02:24:15 PM

Document Has Been Signed on 03/11/2025 02:24 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:MILLHAVEN HOMEFACILITY NUMBER:
435202886
ADMINISTRATOR/
DIRECTOR:		LIGUTOM, FLAMINGOFACILITY TYPE:
735
ADDRESS:107 MILLHAVEN PLACETELEPHONE:
(408) 515-7345
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 0DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Flamingo LigutomTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Flamingo Ligutom.

ADM states that there are no residents currently admitted at the facility. LPA Marrufo conducted a tour of the facility and did not observe any residents or any personal belongings in any of the resident bedrooms.

During visit, LPA tested the smoke detectors in the hallway, living room, and in three out of three resident bedrooms and found them to all function properly when tested. LPA tested one out of one carbon monoxide detector and it functioned properly when tested.

LPA observed locked cabinets in the kitchen to securely store cleaning supplies and sharp utensils.

LPA toured the outside area of the facility and observed both outdoor exits were clear of obstructions.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with ADM Flamingo Ligutom and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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