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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707097
Report Date: 01/22/2025
Date Signed: 01/22/2025 07:02:05 PM

Document Has Been Signed on 01/22/2025 07:02 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:PARK AVENUE ADULT RESIDENTIAL FACILITIESFACILITY NUMBER:
430707097
ADMINISTRATOR/
DIRECTOR:
EUSTAQUIO,CECILIAFACILITY TYPE:
735
ADDRESS:1992 & 1998 PARK AVENUETELEPHONE:
(408) 241-0605
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 12CENSUS: 9DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Diosdado ZabalTIME VISIT/
INSPECTION COMPLETED:
07:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Santino Fortes conducted an unannounced annual inspection, and met with Caregiver (CG) Diosdado Zabal. CG informed that facility has 2 staff and 9 clients. Licensee (LC) was cooking dinner and residents were watching TV in the living rooms and their rooms. 1 resident was asleep.

LPA toured the facility inside out including: 2 kitchens, 2 living rooms, 2 staff room, 6 shared resident rooms and 4 restrooms. Restrooms observed to have non skid flooring. LPAs observed perishable 2 day food supply and non-perishable food supply of at least 7 days. Two Refrigerators temperature observed at 45* degrees F and 3 Freezer temperature were 0 Degrees F. LPA observed an outlet with a broken cover plate. New plate was installed during visit. The front yard and backyard of the facility was also inspected. LPA observed 2 bags of clothing in the hall, 2 boxes of empty clean food containers, pots, kitchen appliances throughout the house. Various bike parts were all around the yard and 2 mattresses were in the middle yard. There was no obstruction to block the outdoor exits. Basement is a storage for bikes and household items.

LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Room temperature was at 68 degree F, and hot water temperature was measured in 2 resident bathroom at 118* and 117* degrees F. LPA inspected the facility first aid kit and it was observed to be complete. The facility was equipped with smoke and carbon monoxide detectors and all functioned properly when tested. Fire extinguishers were last serviced on 10/21/24. The facility conducted their last fire drill on in 2023.

LPA reviewed facility records for 3 staff and 8 clients. LPA reviewed 2 clients medications and centrally stored medication records and were complete.

Deficiencies were cited during today's visit as per California Code of Regulations Title 22. Exit interview was conducted with LC. This report was reviewed and a copy was provided to LC for signature.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Santino Fortes
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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Document Has Been Signed on 01/22/2025 07:02 PM - It Cannot Be Edited


Created By: Santino Fortes On 01/22/2025 at 06:38 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: PARK AVENUE ADULT RESIDENTIAL FACILITIES

FACILITY NUMBER: 430707097

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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The yard and facility was not kept clear clutter which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Licensee will clear yard of kitchen appliances, unused mattresses, bike parts and debris.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 4 bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Licensee will sanitize bathroom floor and shower area. Licensee will remove soiled towels and debris in the bathroom.
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:Jackie Jin
LICENSING EVALUATOR NAME:Santino Fortes
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
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