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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701864
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:44:10 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/28/2024 04:44 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:LYTTON GARDENS COMMUNITY CAREFACILITY NUMBER:
430701864
ADMINISTRATOR/
DIRECTOR:		ANAHI MCKANEFACILITY TYPE:
740
ADDRESS:649 UNIVERSITY AVENUETELEPHONE:
(650) 617-7338
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY: 55CENSUS: 42DATE:
08/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Donna QuickTIME VISIT/
INSPECTION COMPLETED:
05:00 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) David Marrufo conducted an unannounced Case Management - Annual Continuation visit and met with Donna Quick.

During visit, LPA Marrufo measured the water temperature in the hallway bathroom near the facility entrance. LPA observed the water temperature in the bathroom sink to be 122 F. LPA measured the water temperatures in the bathroom sinks of 4 resident living units and the water temperatures were 161 F, 120 F, 122 F, and 124 F.

LPA reviewed 5 staff records and found them to be complete.

LPA Marrufo reviewed facility maintenance records and observed the fire sprinkler system was last tested on 08/19/2024.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information.

This report was reviewed with Donna Quick and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 2
Document Has Been Signed on 08/28/2024 04:44 PM - It Cannot Be Edited


Created By: David Marrufo On 08/28/2024 at 04:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LYTTON GARDENS COMMUNITY CARE
FACILITY NUMBER: 430701864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
87303(e)(2)

1
2
3
4
5
6
7
87303(e)(2) (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot
1
2
3
4
5
6
7
Licensee agrees to submit a Plan of Correction by POC date to CCL stating how the licensee plans to ensure that the water temperatures in the faucets used by residents are between 105 F to 120 F.
8
9
10
11
12
13
14
water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by: the water temperatures in one hallway bathroom and 3 out of 4 observed resident living unit bathrooms were over 120 F, which poses an immediate safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2