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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708478
Report Date: 07/22/2024
Date Signed: 07/22/2024 12:51:06 PM


Document Has Been Signed on 07/22/2024 12:51 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:SANTO NINO RESIDENTIAL CARE HOME #1FACILITY NUMBER:
430708478
ADMINISTRATOR:DHORYDELL SISONFACILITY TYPE:
740
ADDRESS:105 CLAYTON AVENUETELEPHONE:
(408) 295-4112
CITY:SAN JOSESTATE: CAZIP CODE:
95110
CAPACITY:6CENSUS: 4DATE:
07/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lead Staff, Leslie ManaloTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on the Death Repot for resident R1 who was not on Hospice services. LPA Rai met with Lead Staff, Leslie Manalo and stated the purpose of the visit. LPA Rai spoke with Administrator (ADM) Dhorydell Sison over the phone and stated the purpose of the visit.

During visit, LPA Rai obtained the following copies to include but not limited to R1's Admission Agreement, R1's Physician's Report, and R1's After-Visit Summary from recent hospitalization.

ADM stated to submit R1's Appraisal/Needs and Services Plan and R1's Death Report to LPA Rai via email as soon as possible. ADM will provide a copy of R1's Death Certificate once it becomes available.

LPA Rai determined this case management needs further investigation.

This report was reviewed with Lead Staff, Leslie Manalo and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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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