<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294191
Report Date: 09/12/2022
Date Signed: 09/12/2022 03:03:36 PM

Document Has Been Signed on 09/12/2022 03:03 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:KINGDOM HEARTS CARE HOMEFACILITY NUMBER:
435294191
ADMINISTRATOR:ABLAN, ANABELLEFACILITY TYPE:
740
ADDRESS:3664 BRIGADOON WAYTELEPHONE:
(408) 223-3305
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Anabelle AblanTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Anabelle Ablan.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed the facility to have a visitor screening area. The facility had a 30-day supply of PPEs. LPA Marrufo observed a perishable food supply of 2 days and a non-perishable food supply of 7 days. LPA Marrufo observed 2 out of 2 hallway bathrooms to have available soap and paper towels and a hand washing sign. LPA Marrufo toured the outside area of the facility and observed 2 out of 2 outdoor exits were free of obstructions.

No deficiencies were cited at this time as per California Code of Regulations Title 22.


This report was reviewed with Administrator Anabelle Ablan and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1