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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707150
Report Date: 01/15/2025
Date Signed: 01/15/2025 01:11:26 PM

Document Has Been Signed on 01/15/2025 01:11 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:ELLIOTTS HOME IIFACILITY NUMBER:
430707150
ADMINISTRATOR/
DIRECTOR:		ELLIOTT, MARLENEFACILITY TYPE:
735
ADDRESS:1594 INVERNESS CIRCLETELEPHONE:
(408) 723-9423
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 3DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Loren GarciaTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Required 1 Year visit and met with House Manager Loren Garcia. LPA observed 1 staff at the facility. All 3 residents went to day program.

LPA reviewed 2 resident files and 2 staff files. 2 Out of 2 residents' appraisal needs and service plan were observed completed more than one year ago.

License, ADM certificate, and posters of personal rights were observed in the facility.

LPA toured the facility with HM inside and out. LPA inspected living room, family room, dinning area, kitchen, and garage. There are 2 restrooms, 3 resident shared rooms, and 2 staff live-in rooms in facility. At least two days supplies of perishable foods and seven days supplies of nonperishable foods were observed. Fire extinguisher's service date was observed on 5/13/2024. Room temperature was observed at 74 degree F, and hot water temperature was observed at 114 degree F.

Medication cabinet, knife closet, and dish washer liquid closet were observed locked. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 01/01/2025. First aid box, night lights, and flash lights were observed in the facility.

Front yard and back yard were inspected. No obstruction was observed to block the walkway.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with HM. This report was provided to HM for review and signature. A copy of the report was provided to HM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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 01/15/2025 01:11 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 01/15/2025 at 12:10 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: ELLIOTTS HOME II
FACILITY NUMBER: 430707150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the appraisal needs and service plans of residents R1 and R2 were observed completed more than one year ago which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Administrator stated to submit plan of correction by the POC due date to ensure the appraisal needs and service plan of all residents are updated at least annually.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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