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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294191
Report Date: 07/30/2024
Date Signed: 07/30/2024 01:22:26 PM

Document Has Been Signed on 07/30/2024 01:22 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:KINGDOM HEARTS CARE HOMEFACILITY NUMBER:
435294191
ADMINISTRATOR/
DIRECTOR:		ABLAN, ANABELLEFACILITY TYPE:
740
ADDRESS:3664 BRIGADOON WAYTELEPHONE:
(408) 223-3305
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
07/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Administrator Anabelle AblanTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst Manuel Monter conducted an unannounced case management to amend a Case Management-Incident, LIC809, LIC809-C and LIC809-D issued on July 23, 2024. LPA met with Administrator Anabelle Ablan explained the purpose of the visit.

The report issued on July 23, 2024 is being amended to issue a civil penalty and deficiency that was inadvertently not issued during the case management visit.

A Deficiencies is cited during todays visit, see Case Management dated July 23, 2024 LIC809-D. This Report was reviewed with Administrator Anabelle Ablan. A signed copy was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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