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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200281
Report Date: 04/05/2024
Date Signed: 04/05/2024 04:38:27 PM


Document Has Been Signed on 04/05/2024 04:38 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:
04/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ven IgnacioTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with administrator (ADM) Ven Ignacio. LPA checked 3 resident record files and 3 staff record files. 5 residents and 3 staff were observed in the facility. LPA toured the facility inside out with ADM. Facility license, Administrator Certificate, and personal rights posters 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 restroom inside, garage, and laundry room were inspected. Two 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, cleaning product closet was observed locked. Knives closet in the kitchen was observed unlocked. ADM locked the knives closet before LPA left the facility. Room temperature was at 72 degree F, and hot water temperature was at 100 degree F in facility. ADM adjusted the water temperature to 107 degree F before LPA left the facility. The temperature of the refrigerator was at 40 degree F and the temperature of the freezer was at 0 degree F. First aid box and night lights were observed in the facility.

Fire extinguisher was serviced on 04/13/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors and fire alarm system were tested by ADM, and were working fine. ADM tested the sinal system and it was working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. The last time the facility conducted the emergency drill was 11/30/2023.

Citations were noted today. See LIC809-D. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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 4


Document Has Been Signed on 04/05/2024 04:38 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: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 in that the knives closet was observed unlocked which poses an immediate health, safety risk to persons in care. ADM locked the knives closet immediately.
POC Due Date: 04/06/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to lock the knives closet.
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: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/05/2024 04:38 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: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 in that the water temperature was observed at 100 degree F which poses/posed a potential health, safety or personal rights risk to persons in care. ADM adjust the water temperature to be tested at 107 degree F before LPA left the facility.
POC Due Date: 04/12/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to keep the water temperature between 105 and 120 degree F.
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

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 in that the staff files were observed incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to make the staff files complete.
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: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/05/2024 04:38 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: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)(2)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage.

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 in that the residents' centrally stored medication forms were observed inaccurate and not update to date which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to make residents' file accurate and up to date.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

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 in that one of the resident using Oxygen did not have "No Smoking-Oxygen in use" poster posted at the door of the bedroom which poses/posed a potential health, safety rights risk to persons in care. ADM posted the poster immediately.
POC Due Date: 04/12/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to fix the issue.
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: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4