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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202897
Report Date: 12/22/2025
Date Signed: 12/22/2025 12:43:43 PM

Document Has Been Signed on 12/22/2025 12:43 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:FAMILY FEELS RESIDENTIAL CAREFACILITY NUMBER:
435202897
ADMINISTRATOR/
DIRECTOR:		SHIH, YIWENFACILITY TYPE:
740
ADDRESS:781 TERRAZO DRTELEPHONE:
(408) 300-1757
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
12/22/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Mary Jane AcostaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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) Mita Partoza conducted a case management - deficiencies during a complaint investigation and met with Philipp Perez and Mary Jane Acosta who are the designated administrators in the absence of administartor Juliet Pacaldo.

LPA conducted a facility check while doing the investigation, LPA encountered one of the facility staff (S3) who was directly caring for a resident in room 3.

Based on research the Staff 3 (S3) was not listed on the list of staff that were cleared to directly care for residents at the facility on Guardian. LPA requested to review S3's file and found that the S3 submitted a fingerprint scan and was cleared by DOJ on 04/11/2025 and received a response from CA Department of Social Services (CDSS), Care Provider Management Branch (CPMB) on 4/12/2025.

Based on document review, a letter from (CPMB) was sent to the applicant on 08/06/2025, stating that the S3's application was incomplete and if information is not received by 09/22/2025, the background application will be closed. There was no submission from applicant of the required information by CPMB, and the application was closed. S3 status on the Guardian is separated from the facility since 08/14/2025.

Deficiency is cited for not complying with California Code of Regulations (CCR) Title 22 87355 (e)(3). 87761 Penalties(b)Notwithstanding Section 87761(a)... an immediate penalty of $100 per cited violation per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted under Health and Safety Code Section 1569.17(b) has not obtained a California clearance or a criminal record exemption, requested a transfer of a criminal record clearance or requested and be approved for a transfer of an exemption as specified in Section 87355(e) prior to working, residing or volunteering in the facility. An exit interview was conducted with designated administrator Philipp Perez and Mary Jane Acosta. A copy of the report and appeals rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2025
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 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
Document Has Been Signed on 12/22/2025 12:43 PM - It Cannot Be Edited


Created By: Maria Partoza On 12/22/2025 at 11:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: FAMILY FEELS RESIDENTIAL CARE
FACILITY NUMBER: 435202897

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2025
Section Cited
CCR
87355(e)(3)

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e) All individuals...pursuant toHealth and Safety Code Section 1569.17(b) shall prior to working...(3) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:
1
2
3
4
5
6
7
con't - pose, poses a immediate health safety and personal rights risk for persons in care.
8
9
10
11
12
13
14
Based on document review, S3 has a clear FP scan on 4/11/25, but was not received by CPMB. CPMB, notified applicant (S3)regarding incomplete app on 8/14/25. Application was closed by CPMB due to no response received from S3. S3 is separated from the facility. Which
8
9
10
11
12
13
14
Plan of correction: LIC/ADM stated that a written plan of correction will be submitted to LPA by POC due date 12/23/25 stating that the LIC/ADM will call CPMB, to complete S3s requirement for the BG clearance prior to working at the facility.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3