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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707832
Report Date: 05/24/2024
Date Signed: 05/24/2024 11:45:46 AM

Document Has Been Signed on 05/24/2024 11:45 AM - 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:SUB-ACUTE RESIDENTIAL TREATMENT (SART)FACILITY NUMBER:
430707832
ADMINISTRATOR/
DIRECTOR:		MICHELLE MECIRFACILITY TYPE:
772
ADDRESS:230 N. MORRISON AVE.TELEPHONE:
(408) 938-8516
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 16CENSUS: 15DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Fernando PazTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required 1 - year inspection. LPA met with Administrator (ADM), Fernando Paz.

During visit, LPA toured the facility with the ADM to include the resident bedrooms, bathrooms, shower rooms, kitchen, dining room, laundry room, offices, and exterior.

All fire exit routes were free and clear of obstruction. 3 out of 3 staff present are fingerprint cleared and associated to the facility. Residents observed participating in groups during visit.

Facility temperature maintained at 68 - 69 degrees Fahrenheit. Fire extinguisher last services on 09/06/2023. Facility has a carbon monoxide detector present.

Facility kitchen has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 41 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Sharp objects, chemicals, and disinfectants observed secured. Hot water temperature maintained at 116 degrees Fahrenheit. Resident bedrooms equipped with beds, linens, night stands, adequate lighting, and closet space. Bathrooms equipped with grab bars, non-slid floors and hygiene products. Medication room equipped with a complete first aid kit. Emergency numbers posted on the cabinet in the medication room. LPA observed a sharps container. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: SUB-ACUTE RESIDENTIAL TREATMENT (SART)
FACILITY NUMBER: 430707832
VISIT DATE: 05/24/2024
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Facility has an updated emergency disaster plan. Emergency Drills are being conducted quarterly, the last drill was conducted on 05/16/2024. Facility has an updated infection control plan. Staff are provided training on infection control.

Facility's transportation vehicle observed to be registered and serviced. Transportation vehicle contains a first aid kit and fire extinguisher.

LPA reviewed 5 resident records were complete and included a medical assessment, TB result, assessment plan, admission agreement, personal rights, and consent forms. LPA reviewed 5 out of 5 resident centrally stored medications and centrally stored medication records with ADM.

LPA reviewed 3 staff records were complete to include a 1st aid certification, fingerprint clearance, health screening, TB result, and staff training.

Change of Administrator documents were requested to include the board letter, resume, LIC308, LIC501, LIC500, LIC9182, photo ID, Administrator Certificate, and continuing education.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Administrator, Fernando Paz and Licensing Regulations Manager, Lisa Giuliani and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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