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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202736
Report Date: 04/28/2022
Date Signed: 04/29/2022 08:01:22 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/29/2022 08:01 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:KINGDOM HEARTS CARE HOMEFACILITY NUMBER:
435202736
ADMINISTRATOR:ABLAN, RYAN MFACILITY TYPE:
740
ADDRESS:3663 HEATHCOT COURTTELEPHONE:
(408) 262-0425
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 0DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Anabelle Ablan, ADMTIME COMPLETED:
12:19 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) Steve Chang conducted an unannounced annual inspection visit today. Upon arrival, LPA cannot enter the facility, LPA called administrator (ADM) Anabelle Ablan, and ADM asked LPA to wait for 20 minutes to wait for ADM to come.

LPA met with ADM after waiting 25 minutes outside, and entered the facility. ADM stated the facility is non operational for more than two years. LPA did not see any COVID posters on the main door. LPA did see any COVID posters in facility. LPA did not see any screening station in facility.

LPA toured the facility inside out with ADM. Living room, dinning room, kitchen, family room were observed. There are 4 single bedrooms, 1 shared bedroom, and two restrooms in facility. Front yard and backyard were inspected. No resident or staff were observed in facility.

ADM stated no one lives in facility, and the facility is non operational for more than two years. LPA observed this facility is at non operational status.

LPA suggested ADM to close the facility if the facility is at non operational status.

Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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