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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201557
Report Date: 10/23/2023
Date Signed: 10/23/2023 09:45:27 AM

Document Has Been Signed on 10/23/2023 09:45 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:PRUNERIDGE RESIDENTIAL CARE HOMEFACILITY NUMBER:
435201557
ADMINISTRATOR:CORTES, LEILANIFACILITY TYPE:
740
ADDRESS:3030 PRUNERIDGE AVENUETELEPHONE:
(408) 247-2771
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 6CENSUS: 6DATE:
10/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Lead Caregiver, Rose (Rosalia) CalungcaginTIME COMPLETED:
09:45 AM
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) Simi Rai conduced an unannounced case management visit and met with Lead Caregiver, Rose (Rosalia) Calungcagin. LPA Rai stated the purpose of today's visit to assess the facility's request for an exception for R1's prohibited condition.

The licensee has submitted an exception request for R1 who is depend on others to perform all activities of daily living. Staff were interviewed concerning R1's care and the requirement of the exception. R1 is not receiving Hospice services at this time.

At approximately 8:32pm, LPA Rai observed R1 in a reclined position in bed. R1 was awake and LPA Rai attempted to conduct an interview but R1 did not respond to questions. R1 was not able to move arms, legs or hands. R1 was observed with contractures in the hands and R1 was unable to grab items such as a glass of water or hairbrush. S1 stated the facility staff provide assistance to R1 in all areas of activity of daily living.

At this time, the Department is reviewing Licensee's request for the exception for R1.

No deficiencies were cited. Exit interview conducted with Lead Caregiver, Rose (Rosalia) Calungcagin. A copy of this report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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