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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294181
Report Date: 06/29/2022
Date Signed: 06/29/2022 04:25:10 PM


Document Has Been Signed on 06/29/2022 04:25 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
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: 6DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary Ann Villanueva and Concordia CasabarTIME COMPLETED:
04:40 PM
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On 06/29/2022, Licensing Program Analysts (LPAs) Mandeep Kaur and David Marrufo visited the facility to conduct the unannounced annual inspection visit.

Upon Entry, LPAs temperature was checked and COVID screening was done by Care Giver Mary Ann Vilanueva.

LPAs toured the facility with care giver Mary Ann Vilanueva. Water temperature was checked at 119.5 degree and facility temperature is 81.1 degree.

LPAs observed kitchen area, 6 out of 6 bedrooms and 1 bathroom. There was sufficient perishable food for at least 2 days and nonperishable food for at least one week. Facility has Menu for 3 meals and snacks to the clients. Facility has 30 days of PPE supplies. LPAs observed Facility has cleaning supply locked in the laundry room.

LPAs observed the outdoor area. The outdoor exits are clear of obstruction.

No deficiency were cited as per California code of regulations Title 22.

Report was reviewed with Mary Ann Villanueva and copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 726-4986
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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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