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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294181
Report Date: 05/02/2024
Date Signed: 05/02/2024 02:54:13 PM


Document Has Been Signed on 05/02/2024 02:54 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: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:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Lead Staff, Mary Ann VillanuevaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Lead Staff (LS) Mary Ann Villanueva. LPA Rai spoke with Licensee/Administrator over the phone and obtained verbal authorization for LS to review and sign the report. LPA Rai observed 2 staff and 6 residents at the facility. At this time, the facility has 2 hospice residents.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 2 sheds which are not used as habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids.

Fire extinguisher was observed and inspected on 01/05/2024.

LPA will return another day to complete annual inspection. This report was reviewed with Lead Staff (LS) Mary Ann Villanueva and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
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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