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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294191
Report Date: 09/23/2021
Date Signed: 09/23/2021 02:52:11 PM

Document Has Been Signed on 09/23/2021 02:52 PM - 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:
435294191
ADMINISTRATOR:ABLAN, ANABELLEFACILITY TYPE:
740
ADDRESS:3664 BRIGADOON WAYTELEPHONE:
(408) 223-3305
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 4DATE:
09/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Annabel AblanTIME COMPLETED:
01:00 PM
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Licensing Program Analyst, Steve Nguyen, conducted an unannounced 1 year inspection at facility with Administrator (AD), Annabel Ablan.

AD stated that renovation began on 9/14/2021 and with a tentative completion date of October 15, 2021.

AD acknowledge that in future, facility will inform Department prior to any renovation and submit a plan of care to demonstrator how facility will minimize the renovation's impact on residents.

AD acknowledge and will retrain staff's covid mitigation process: i.e., screening protocols to adhere with most current PINS.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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