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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708478
Report Date: 03/13/2025
Date Signed: 03/13/2025 03:09:01 PM

Document Has Been Signed on 03/13/2025 03:09 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: 6CENSUS: 4DATE:
03/13/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator, Dhorydell SisonTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Mita Partoza and Marcella Tarin conducted an unannounced complaint investigation and observed deficiencies while conducting inspection. A case management was initiated for the deficiencies that were found during the complaint investigation that is not related to the complaint.

During the tour LPAs observed 3 resident R1-R3, and 1 staff. R1, R2 were watching TV in the living room, and R3 was in their bedroom. LPAs observed staff (S1) was in the kitchen preparing food. LPAs observed Licensee in staff room with S1s grandchild under the age of 5. R4 arrived after an hour.

LPAs toured the interior and exterior of the facility and observed that the facility required maintenance, 4 bedroom were observed to have unknown powder residue on the floor. ADM stated it was sprayed by the exterminator to prevent bedbugs from repopulating. LPAs observed dust and cobwebs throughout the facility, a broken window screen outside bedroom #4, an uncovered waste basket in bedroom #1 with unknown stain brown in color and splattered on the wall next to the waste basket. LPAs observed Comet cleaning product in a bathroom, accessible to residents in care.

During the visit, LPAs requested for one resident record file and observed R4s file did not contain a current LIC602, the last assessment recorded was on 9/7/2020. ADM stated that he/she was not aware that LIC 602s (Physician's Report) needs to be updated. LPAs provided a technical assistance to ADM regarding updating medical assessment as required by the Department. During the facility's annual inspection on 12/26/2024, deficiencies were issued for records not being available for LPAs review.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. An exit interview was conducted with Administrator Dhorydell Sison and a copy of the report and appeal rights were provided.
Jin Jackie
Marcella Tarin
DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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 03/13/2025 03:09 PM - It Cannot Be Edited


Created By: Marcella Tarin On 03/13/2025 at 01:32 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: SANTO NINO RESIDENTIAL CARE HOME #1
FACILITY NUMBER: 430708478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2025
Section Cited

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87303 Maintenance and Operation (a) The
facility shall be...in good repair at all times,...for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by
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Based on observation the licensee did not ensure the facility was in good repair at all times. LPAs observed dust, cobwebs, a broken window screen exterior of Bedroom 4, uncovered waste basket in bedroom 1 with unknown brown residue on the wall next to the waste
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cont.--basket, which poses an immediate health, safety, or personal rights risk to 4 residents in care.
Type A
03/13/2025
Section Cited

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Storage Space and Acess
(a) .. the licensee shall ensure that disinfectants, cleaning solutions... which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
This requirement is not met as evidenced by
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Based on observaton and the licensee did not ensure cleaning solutions were inaccessible to 4 residents in care. LPAs observed Comet cleaning product on top of a toilet in bathroom outside of bedroom #2, which poses an immediate health, safety, or personal rights risk to 4 residents in care.
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Licensee removed Comet cleaning product during visit. Licensee states that all staff will be instructed to remove and lock cleaning products away. Licensee will submit a written statement of understanding of the regulation cited to the Department by POC due date 3/14/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
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