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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200327
Report Date: 01/22/2025
Date Signed: 01/22/2025 03:42:04 PM

Document Has Been Signed on 01/22/2025 03:42 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/
DIRECTOR:		ANGELINA ESCOBARFACILITY TYPE:
740
ADDRESS:675 HIGH GLEN DRIVETELEPHONE:
(408) 923-2784
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Administrator Angelina EscobarTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Angelina Escobar, Administrator/Licensee. LPA announced the purpose of the visit. LPA observed 6 residents in care and 2 staff. LPA observed room temperature to be at 72 degrees F.

During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed 3 cans of expired food ADM removed them and discarded them. ADM was reminded to check the dates frequently and discard any food that is expired. Refrigerator temperature measured at 40 degrees F and freezer was 0 degrees F.

LPA toured 5 resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 110-111 degrees F. LPA observed 2 linen closets and Laundry area used to do laundry.

ADM tested the smoke detector in the hallway and found the smoke detector to function properly when tested. Facility has a Fire Pull alarm which was last serviced on 06/24/24.

LPA observed posters located by the front entrance for Long Term Care Ombudsman and Employee Rights and Residents Rights.

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Romeo ManzanoTELEPHONE: (650) 388-2297
Marcela YanezTELEPHONE: (279) 789-1062
DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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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
VISIT DATE: 01/22/2025
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LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 06/24/24. LPA reviewed Fire and Earthquake log and last disaster drill was conducted on 11/17/24.

LPA reviewed resident records for 3 residents and Centrally Stored Medication Record (CSMDR) and found to be complete. LPA reviewed 2 Residents Hospice file which included Hospice Plan and visit log and progress notes.

LPA reviewed 3 staff records and found them to be complete.

No deficiency were cited as per California Code of Regulations Title 22. Technical Violation was issued today for 87555 (b)(8) (see LIC9102) This report was reviewed with Administrator Angelina Escobar and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
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