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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201557
Report Date: 11/20/2024
Date Signed: 11/20/2024 11:03:01 AM

Document Has Been Signed on 11/20/2024 11:03 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/
DIRECTOR:		CORTES, LEILANIFACILITY TYPE:
740
ADDRESS:3030 PRUNERIDGE AVENUETELEPHONE:
(408) 247-2771
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 6CENSUS: 6DATE:
11/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Lead Caregiver, Rose (Rosalia) CalungcaginTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on the Type A and Type B deficiencies cited on 9/24/2024. LPA Rai met with Lead Caregiver (S1), Rose (Rosalia) Calungcagin and stated the purpose of today's visit. S1 notified Licensee/Administrator Leilani Cortes of LPAs' visit and S1 stated Licensee/Administrator was busy at the time and unable to be present during today's visit. LPA Rai observed 2 staff and 6 residents in the facility.

During visit, LPA Rai inspected the kitchen area. LPA Rai observed at random canned foods in the cabinet and 10 out of 10 canned foods were not expired. LPA Rai observed sharps, such as knives, and toxic chemicals locked in cabinet and inaccessible to residents. LPA Rai observed medications were in the locked cabinet and inaccessible to residents.

During visit, LPA Rai inspected the backyard and garage. LPA Rai observed the gardening tools and toxic chemicals were locked and inaccessible to residents in care.

During visit, LPA Rai inspected the designated office. 2 Out of 2 staff stated the office is not being used as a bedroom and is currently being used as a storage space.

During visit, LPA Rai reviewed staff S1's Statement of Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders.

During visit, LPA Rai provided letter of the Deficiency Citations cleared.

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

This report was reviewed with Lead Caregiver, Rose (Rosalia) Calungcagin and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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