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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708102
Report Date: 07/05/2024
Date Signed: 07/05/2024 04:29:34 PM


Document Has Been Signed on 07/05/2024 04:29 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:MERTZ CARE HOMEFACILITY NUMBER:
430708102
ADMINISTRATOR:MERTZ, ELVIRAFACILITY TYPE:
740
ADDRESS:2715 MCLAUGHLIN AVENUETELEPHONE:
(408) 483-2748
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 2DATE:
07/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Lead Staff Rogeine JimenezTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Lead Staff Rogeine Jimenez (S1). During visit, LPA observed 1 residents and 2 staff.

LPA toured the facility inside out with S1 which included; the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. LPA observed a pool in the backyard with a lock on the gate door. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 80 degrees F, and hot water temperature was measured at 108 degrees F in both resident bathrooms.

Fire extinguisher was serviced in January 9, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on July 5, 2024.

LPA reviewed facility records for 2 staff and 2 residents. LPA reviewed 2 resident medications and centrally stored medication records. LPA reviewed 2 residents P&I records. LPA conducted interviews with 1 staff and 2 residents.

No deficiencies cited during today's visit. This report was reviewed with Lead Staff Rogeine Jimenez and a copy of the signed report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024
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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