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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294074
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:05:06 PM


Document Has Been Signed on 09/14/2022 04:05 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:GOLDEN FACILITIES & SERVICESFACILITY NUMBER:
435294074
ADMINISTRATOR:MABUTAS, FELYFACILITY TYPE:
740
ADDRESS:3884 WIVEN PLACE WAYTELEPHONE:
(408) 440-4725
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: DATE:
09/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection. LPA spoke with Administrator, Fely Mabutas over the phone who confirmed the facility had closed as of May 2022.

LPA spoke with the current operator over the phone who stated the facility is currently an independent living home as of August 2022. The operator stated the tenants are all independent.

Administrator is informed to surrender the license to the Department.

This report was reviewed with Fely Mabutas over the phone who was not physically available to sign the report.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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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