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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200391
Report Date: 06/23/2025
Date Signed: 06/23/2025 02:23:47 PM

Document Has Been Signed on 06/23/2025 02:23 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:EMPLOY AMERICAFACILITY NUMBER:
435200391
ADMINISTRATOR/
DIRECTOR:		MERITA AMITUANAIFACILITY TYPE:
775
ADDRESS:124 BLOSSOM HILL RD, STE. FTELEPHONE:
(408) 574-3950
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 45CENSUS: 20DATE:
06/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Dulce Moreno and Merita AmituanaiTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility and met with program director Dulce Moreno. There are 20 clients and 6 staff present. Clients are developmentally disabled and are overseen by San Andreas Regional Center.
Facility consists of reception area, activity areas, kitchen, 2 bathrooms, isolation room, storage room, and 5 offices. The facility does not provide meals as clients bring their own meals and snacks from their respective homes. Facility is observed to be clean and well maintained. Four exits are clear of obstruction.

Smoke alarm and carbon monoxide detectors were inspected by third party vendor on 5/21/25 and the detectors are noted to be in working condition. First aid kit is observed complete. The last disaster drills were conducted on 6/17/25 and 5/27/25. Hot water temperature in restroom sink tested at 107 degrees F.
Random staff and client records reviewed.

The following forms/information are requested to be submitted to CCLD BY 7/7/25:
- Administrative Organizatioin (LIC309)
- Designation of Administrative Responsibility (LIC308)
- Personnel Report (LIC500)
- proof of control of property (signed, dated lease agreement)

Infection Control Plan and updated Emergency Disaster Plan (LIC610D) are given to LPA today.

Deficiencies of the California Code of Regulations, Title 22 is observed and cited on a following page.

Report reviewed program director and a copy of the signed report was provided.
NAME OF LICENSING PROGRAM MANAGER: Cowan April
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/23/2025 02:23 PM - It Cannot Be Edited


Created By: Audrey Jeung On 06/23/2025 at 01:58 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: EMPLOY AMERICA
FACILITY NUMBER: 435200391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, 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 licensee did not comply with the section cited above, as Comet cleanser and liquid cleaners are stored in unlocked cabinets in storage room and kitchen, accessible to program participants. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
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Cleaning products were relocated to locked cabinet in kitchin in LPA's presence.
Deficiency corrected and cleared
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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/23/2025 02:23 PM - It Cannot Be Edited


Created By: Audrey Jeung On 06/23/2025 at 01:58 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: EMPLOY AMERICA
FACILITY NUMBER: 435200391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(g)(1)
Personnel Requirements
(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff records, the licensee did not comply with the section cited above in 2 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- TB test results are not available for Staff #2 and #5
POC Due Date: 06/23/2025
Plan of Correction
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TB test results for S2 and S5 provided to LPA during visit.
Deficiency corrected and cleared.
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of client record, the licensee did not comply with the section cited above in 1 out of 6 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- Medical assessment for client #5 is incomplete, as there is no MD name, signature or date.
POC Due Date: 07/07/2025
Plan of Correction
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Completed, signed and dated medical assessment for client #5 will be sent to CCLD BY DUE DATE. Report shall include client's ambulatory status.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2025


LIC809 (FAS) - (06/04)
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