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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294181
Report Date: 10/26/2021
Date Signed: 10/28/2021 12:36:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PRUNERIDGE RESIDENTIAL CARE HOME, FACILITY #2FACILITY NUMBER:
435294181
ADMINISTRATOR:CORTES, LEILANI F.FACILITY TYPE:
740
ADDRESS:2575 FOREST AVENUETELEPHONE:
(408) 985-1982
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:6CENSUS: 5DATE:
10/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maryann VillanuevaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) conducted an unannounced Case Management - Other visit. The purpose of the visit was that LPA received 1 exception request of 1 resident (R1) who depends on others for all activities of daily living. LPA met with the caregiver-in-charge Maryann Villanueva.

LPA assessed R1 on her wheelchair in the living room. R1 was able to communicate with LPA. LPA observed R1 being able to scratch herself, able to run her hands through her hair, and able to hold a comb to brush hair. R1 was able to hold a cup to drink water with the assist from the staff.

At this time, R1 was not deemed dependent on others for all activities of daily living.

No deficiency cited during visit today.

This report was reviewed with Maryann Villanueva. A copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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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