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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200281
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:47:20 PM


Document Has Been Signed on 04/14/2023 04:47 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:DRY CREEK GUEST HOMEFACILITY NUMBER:
435200281
ADMINISTRATOR:IGNACIO, ESTHER L.FACILITY TYPE:
740
ADDRESS:1856 DRY CREEK ROADTELEPHONE:
(408) 559-6010
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 5DATE:
04/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Ven IgnacioTIME COMPLETED:
04:19 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Licensee (LNS) Ven Ignacio.

LPA checked 5 resident record files (R1 - R5) and 4 staff record files (S1 - S4). 5 residents (R1 - R5) and 2 staff (S3 - S4) were interviewed. Personnel Records were observed incomplete.

LPA toured the facility inside out with LNS. Facility license, Administrator Certificate, were observed posted at the facility. Living room, family room, kitchen, dinning room and two and half restrooms were inspected. Six single resident bedrooms which including 3 bedrooms with bathroom inside, and laundry room were inspected. One staff live-in rooms are in facility. Non-skid mats and grab bars were observed in bathrooms.

Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet knives closet was observed locked. Cleaning product closet and knives closet in the kitchen were observed unlocked. Room temperature was at 72 degree F, and hot water temperature was at 107 degree F in facility.

Fire extinguisher was serviced on 04/28/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors and fire alarm system were tested by LNS, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Citation were noted today. See LIC809-D. Exit interview was conducted with LNS. This report was provided to LNS for signature. A copy of the report was provided to LNS. Appeal Rights form was provided to LNS.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 04/14/2023 04:47 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: DRY CREEK GUEST HOME
FACILITY NUMBER: 435200281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space
(a) Disinfectant, cleaning solutions, poisons, firearms, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the knives closet and detergent closet in the kitchen were observed unlock, the licensee did not comply with the section cited above, which poses an immediate health, safety risk to persons in care.
POC Due Date: 04/15/2023
Plan of Correction
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Licensee/Administrator agreed to submit Plan of Correction by the POC due Date which provides the finished date of adding locks to knives closet and detergent closet in the kitchen to lock knives closet and detergent closet in the kitchen.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3


Document Has Been Signed on 04/14/2023 04:47 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: DRY CREEK GUEST HOME
FACILITY NUMBER: 435200281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licnesee, administrator, and each employee. Each personnel record shall contain the following information:
(11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the personnel records for 3 out of 4 staff are missing health screening information, the licensee did not comply with the section cited above in 3 out of 4 staff which poses/posed a potential health rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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Licensee/Administrator agreed to submit Plan of Correction by the POC due date to complete staff health screening information.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
LIC809 (FAS) - (06/04)
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