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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708478
Report Date: 12/26/2024
Date Signed: 12/26/2024 06:44:18 PM

Document Has Been Signed on 12/26/2024 06:44 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/
DIRECTOR:		DHORYDELL SISONFACILITY TYPE:
740
ADDRESS:105 CLAYTON AVENUETELEPHONE:
(408) 295-4112
CITY:SAN JOSESTATE: CAZIP CODE:
95110
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Administrator Dhorydell SisonTIME VISIT/
INSPECTION COMPLETED:
06:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Dhorydell Sison. During the visit, LPA observed 4 residents and 2 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the bathroom next to bedroom #2, LPA observed the sliding shower door was stuck. ADM stated she doesn't know how long its been stuck. LPA also observed the screens in the bathroom windows between bedroom #3 and & 2 had dirt/grime on the screens (Photographs were taken.) While touring the bathroom closest to bedroom #3, LPA observed the sink was clogged. (Photograph was taken.)

While touring the outside of the facility, LPA observed the screen door, from the backyard, leading into bedroom #4. LPA observed the screen door had dirt & grime. (Photographs were taken.)

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 111 degrees F in resident bathrooms.

Fire extinguisher was serviced in December 24, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. ADM stated she does not have a fire drill log. Page 1 Out of 3.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112
DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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: SANTO NINO RESIDENTIAL CARE HOME #1
FACILITY NUMBER: 430708478
VISIT DATE: 12/26/2024
NARRATIVE
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LPA reviewed facility records for 3 residents. LPA requested to review R1-R3's preadmission appraisal. ADM was unable to provide LPA with a copy to review. LPA requested to review R3's needs and Services plan. ADM stated she has not completed R3's Needs and Services Plan. LPA requested to review R1-R3's Consent form, (LIC627C). ADM was unable to provide LPA with a copy to review. LPA requested to review R1-R3's Personal rights of Residents in publicly operated residential care facilities for the elderly (LIC613C), ADM was unable to provide LPA with a copy to review. LPA requested to review R1-R3's Resident Personal Property & Valuables form, (LIC621). ADM stated she has not filled out this form for R1-R3. LPA requested to review R2-R3's ID and Emergency information form ( LIC601). ADM was unable to provide LPA with a copy to review.

LPA reviewed facility records for 2 staff. LPA requested to review S1's training records and first aid training. ADM stated S1 has not completed his/her training for 2024 or his/her first aid training either. LPA requested to review S1's SOC341A. ADM was unable to provide S1's SOC341A form. LPA requested to review ADM's documents. ADM stated she has the completed all the required documents but has them on her computer. ADM stated her printer does not work.

LPA reviewed 3 resident medications and centrally stored medication records. While reviewing R1's centrally stored medication log, LPA observed the log did not have start dates for 5 medications. (Photograph taken.) While reviewing R3's Medications, LPA observed medication M1 was not listed on the Centrally stored medication log. (Photograph taken.). LPA conducted interviews with 1 staff and 2 residents.

During today's visit, LPA followed up on the case management conducted on 7/22/2024. LPA Rai was investigating R4's death at the facility, and was not in hospice services. Based on R4's death certificate, R4's cause of death was probable complication of an existing health condition.

LPA provided ADM with a flyer "Important updates to Dementia Care & Miscellaneous Changes, Effective January 1, 2025."

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/26/2024 06:44 PM - It Cannot Be Edited

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: SANTO NINO RESIDENTIAL CARE HOME #1
FACILITY NUMBER: 430708478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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. LPA observed the bathroom next to bedroom #2, had the sliding shower door which was stuck. ADM stated she doesn't know how long its been stuck. the bathroom closest to bedroom #3, LPA observed the sink was clogged. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure the facility is in good repair at all times, and how she will address the shower door and clogged sink. ADM stated she will send the written plan of action by POC date, 01/02/2025.
Section Cited
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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. LPA observed the screens in the bathroom windows between bedroom #3 and & 2 had dirt/grime on the screens. LPA observed the screen door, from the backyard, leading into bedroom #4 had dirt & grime. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure All window screens shall be clean and maintained in good repair. ADM stated she will send photo documentation showing the screens are clean and in good repair. ADM stated she will send the written plan of action by POC date, 01/02/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112

DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/26/2024 06:44 PM - It Cannot Be Edited

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: SANTO NINO RESIDENTIAL CARE HOME #1
FACILITY NUMBER: 430708478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review ADM's documents. ADM stated she has the completed all the required documents but has them on her computer. ADM stated her printer does not work. ADM did not provide copies for LPA to audit. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send the plan of action to LPA by POC date, January 2, 2025.
Section Cited
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review S1's training records and first aid training. ADM stated S1 has not completed his/her training for 2024 or his/her first aid training either. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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ADM stated she complete staff S1's training and send documentation showing his/her annual training has been completed. ADM stated she will also send documentation showing S1 has completed his/her first aid training as well. ADM stated she will send the plan of action to LPA by POC date, January 2, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112

DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024

LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 12/26/2024 06:44 PM - It Cannot Be Edited

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: SANTO NINO RESIDENTIAL CARE HOME #1
FACILITY NUMBER: 430708478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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. Resident R1-R3 did not have the following forms in there file: LIC627C, LIC613. Residents R2-R3 did not have a LIC601 in there file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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ADM stated she would complete the noted missing documents for the residents mentioned in the deficient practice statement. ADM stated she will send the plan of action to LPA by POC date, January 2, 2025.
Section Cited
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview the licensee did not comply with the section cited above. LPA requested to review R1-R3's Resident Personal Property & Valuables form, (LIC621). ADM stated she has not filled out this form for R1-R3. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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ADM stated she would fill out the LIC621 form for all residents. ADM stated she would send LPA a copy of the completed form by POC date. ADM stated she will also send a letter of understanding regarding the regulation. ADM stated she will send the plan of action to LPA by POC date, January 2, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112

DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024

LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 12/26/2024 06:44 PM - It Cannot Be Edited

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: SANTO NINO RESIDENTIAL CARE HOME #1
FACILITY NUMBER: 430708478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review R1-R3's preadmission appraisal. ADM was unable to provide LPA with a copy to review. ADM stated the form was not filled out. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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ADM stated she would fill out the forms and send LPA a copy. ADM stated she will also send a letter of understanding regarding the regulation. ADM stated she will send the plan of action to LPA by POC date, January 2, 2025.
Section Cited
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review R3's needs and Services plan. ADM stated she has not completed R3's Needs and Services Plan. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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ADM stated she will complete R3's needs and services plan and send LPA a copy. ADM stated she will also send a letter of understanding regarding the regulation. ADM stated she will send the plan of action to LPA by POC date, January 2, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112

DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024

LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 12/26/2024 06:44 PM - It Cannot Be Edited

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: SANTO NINO RESIDENTIAL CARE HOME #1
FACILITY NUMBER: 430708478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review the facility fire/earthquake/disaster drill log. ADM stated she does not have a log. This poses/posed a potential health, safety or personal rights risk to persons in care. ADM stated she will send the plan of action to LPA by POC date, January 2, 2025.
POC Due Date: 01/02/2025
Plan of Correction
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ADM stated she will create a fire/earthquake/disaster drill log. ADM stated she will conduct a drill and send LPA documentation showing a drill has taken place. ADM
Section Cited
87465 Incidental Medical and Dental Care (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

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. While reviewing R1's centrally stored medication log, LPA observed the log did not have start dates for 5 medications. While reviewing R3's Medications, LPA observed medication M1 was not listed on the Centrally stored medication log. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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ADM Added R3's medication to the Centrally stored log during visit. ADM stated she would audit R1's medications to put the start date for the 5 medications that are missing there start date. ADM stated she would also send a letter of understanding regarding the regulation. ADM stated she will send the plan of action to LPA by POC date, January 2, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112

DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024

LIC809 (FAS) - (06/04)
Page: 7 of 8
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: SANTO NINO RESIDENTIAL CARE HOME #1
FACILITY NUMBER: 430708478
VISIT DATE: 12/26/2024
NARRATIVE
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LPA requested a copy of the following documents:
1.LIC 500, Personnel Summary 2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources 4. Liability Insurance
5. Qualifications of Administrator (Certificate) 6. Copy of surety bond
7. Please review your facility program for updates (incorporating new laws and/or regulations)

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Dhorydell Sison and a copy of the signed report was provided.

Page 3 Out of 3. END OF REPORT.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC809 (FAS) - (06/04)
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