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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294178
Report Date: 02/21/2024
Date Signed: 02/21/2024 12:56:12 PM


Document Has Been Signed on 02/21/2024 12:56 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:ANGELS SENIOR CARE HOMEFACILITY NUMBER:
435294178
ADMINISTRATOR:LUO, XI-HUAFACILITY TYPE:
740
ADDRESS:4078 FREED AVENUETELEPHONE:
(408) 244-7689
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:6CENSUS: 6DATE:
02/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Xi-Hua LuoTIME COMPLETED:
01:05 PM
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Licensing Program Analyst Manuel conducted an unannounced case management visit to amend a facility evaluation report that was issued on January 27, 2024, to add additional information.

LPA met with Administrator Xi-Hua Luo and explained the purpose of the visit.

No deficiencies cited. A copy of the report was provided to Administrator Xi-Hua Luo
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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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