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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202910
Report Date: 11/20/2023
Date Signed: 11/30/2023 04:48:06 PM

Document Has Been Signed on 11/30/2023 04:48 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:MANFRED CARE HOME LLCFACILITY NUMBER:
435202910
ADMINISTRATOR:DUMANTAY, MADONNAFACILITY TYPE:
735
ADDRESS:2389 RENFIELD WAYTELEPHONE:
(408) 818-0134
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
11/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Applicant, Madonna DumantayTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Simi Rai arrived announced to conduct the facility's pre-licensing continuation visit. LPA met with Applicant, Madonna Dumantay. This location has an operating facility and LPA Rai observed 3 residents and 6 staff present at the facility.

LPA Rai went over COMPONENT III with applicant.

No issues noted during this pre-licensing inspection today.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Applicant, Madonna Dumantay and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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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