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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202753
Report Date: 04/26/2024
Date Signed: 04/26/2024 11:14:04 AM

Document Has Been Signed on 04/26/2024 11:14 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:HEATHERFIELD INNFACILITY NUMBER:
435202753
ADMINISTRATOR/
DIRECTOR:		NGUYEN, DIEU-QUI HFACILITY TYPE:
740
ADDRESS:1021 HEATHERFIELD LANETELEPHONE:
(408) 621-9887
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 9CENSUS: 5DATE:
04/26/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Carmina AmaralTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Collateral visit and met with Carmina Amaral.

During visit, LPA Marrufo interviewed a resident as part of a complaint investigation for another facility.

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

This report was reviewed with Carmina Amaral and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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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