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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200327
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:00:07 PM


Document Has Been Signed on 01/25/2024 02:00 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:LORRIE RESIDENTIAL CARE HOME IVFACILITY NUMBER:
435200327
ADMINISTRATOR:ANGELINA ESCOBARFACILITY TYPE:
740
ADDRESS:675 HIGH GLEN DRIVETELEPHONE:
(408) 923-2784
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY:6CENSUS: 6DATE:
01/25/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angelina EscobarTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mita Partoza conducted an unannounced continuance of the required annual visit. LPA met with administrator and licensee (ADM/LIC) Angelina Escobar.

During today's visit, LPA and ADM. conducted medication review of 3 residents (R1-R3) and found R1 missed medications.

ADM/LIC stated they do not keep a daily log for administered medication or Medication Administration Report (MAR) to monitor daily medication intake.

Deficiency were cited per California Code of Regulations, Title 22 during today's visit. This report was reviewed with administrator Angelina Escobar and a copy of the report was provided to the administrator/licensee.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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 2


Document Has Been Signed on 01/25/2024 02:00 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: LORRIE RESIDENTIAL CARE HOME IV
FACILITY NUMBER: 435200327

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)


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 1 out of 1 identifier which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Licensee/administrator stated a training will be provided to staff for medication administration and record keeping and the plan of correction is due on 1/26/2024 before the end of the day.
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: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2