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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200432
Report Date: 04/21/2022
Date Signed: 04/21/2022 12:20:58 PM

Document Has Been Signed on 04/21/2022 12:20 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:CARRANZA #1FACILITY NUMBER:
435200432
ADMINISTRATOR:CARRANZA, EDUARDOFACILITY TYPE:
735
ADDRESS:2052 LADDIE WAYTELEPHONE:
(408) 809-4715
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 4DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:GabrielTIME COMPLETED:
12:23 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 04/21/2022 at 09:45am. LPA met with facility staff member Romeo Alvarez (S1). Administrator Eduardo Caranza (Admin) arrived at the facility after the inspection was completed.

LPA toured the facility, including kitchen, living room, garage, 4 resident bedrooms, one staff bedroom, two bathrooms, and backyard. Staff members were not observed to be wearing masks. S1 confirmed that all staff and residents have been vaccinated.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in November 2021. 2 smoke alarms were tested and observed to be functioning properly. All cleaning supplies and chemicals noted to be in locked cabinets and closets.

Facility did not have a designated entry point, visitor and resident entrances were noted to be separate. Staff did not take LPA's temperature nor screen for symptoms. Facility did not have sufficient PPE supplies, LPA did not observe N95s or a sufficient number of gowns/face shields available at the premises. Hand washing signs were observed in facility bathrooms. Water temperature observed to be 136.4 *F in two sinks, 16.4 *F over the limit. Shower temperature observed to be 105.3 *F. Social distancing signs observed to be posted in all public areas.

Deficiency cited during today's visit. See 809-D. Advisory notes issued. This report was reviewed with Administrator Eduardo Caranza and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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 14
Document Has Been Signed on 04/21/2022 12:20 PM - It Cannot Be Edited


Created By: Ryker Heberle On 04/21/2022 at 11:43 AM
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: CARRANZA #1
FACILITY NUMBER: 435200432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088(e)(1) Furniture, Fixtures, Equipment, and Supplies - (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 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 as demonstrated by two sinks outputing water with a temperature of 136.4 *F, 16.4 degrees over the limit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Licensee to schedule visit from plumber to address disparity in water temperature between showers and sinks by POC due date and provide proof of repair upon completion.
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:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


LIC809 (FAS) - (06/04)
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