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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201493
Report Date: 02/26/2025
Date Signed: 02/26/2025 09:27:07 AM

Document Has Been Signed on 02/26/2025 09:27 AM - 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:A HEAVENLY CARE HOMEFACILITY NUMBER:
435201493
ADMINISTRATOR/
DIRECTOR:		FONTANILLA, DIANAFACILITY TYPE:
740
ADDRESS:259 CHECKERS DRIVETELEPHONE:
(408) 926-3285
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6CENSUS: 3DATE:
02/26/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Administrator Diana FontanillaTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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On January 16, 2025, LPA Monter conducted a case management POC visit. LPAs met with Administrator, Administrator Diana Fontanilla

On January 31, 2025, the facility was issued the following citations during a case management - deficiencies. The deficiencies cited had a POC due date of February 1, 2025 for the Type A deficiency and February 7, 2025 for the Type B deficiency.

The following deficiencies were cleared during visit:
Type A - 87468.1 Personal Rights of Residents in All Facilities (a)(1)
Type B - 87303 Maintenance and Operation (a)

No deficiencies cited during todays visit. This report was reviewed with A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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