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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200432
Report Date: 01/11/2024
Date Signed: 01/11/2024 10:39:25 AM

Document Has Been Signed on 01/11/2024 10:39 AM - 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:CARRANZA #1FACILITY NUMBER:
435200432
ADMINISTRATOR:CARRANZA, EDUARDOFACILITY TYPE:
735
ADDRESS:2052 LADDIE WAYTELEPHONE:
(408) 809-4715
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Administrative Assistant Ernie ManaoisTIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrative Assistant (AA) Ernie Manaois . During visit, LPA observed 5 residents and 1 staff.

LPA toured the facility inside out with AA which included; the Living room, kitchen, dining room, 2 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication cabinet, knives storage cabinet, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 118 degrees F in both resident bathrooms.

While touring the home with AA, LPA observed Bedroom #2's window did not have a window screen. (Photograph was taken.) While touring bedroom #1, LPA observed the sliding door screens were also missing in the Atrium open space. (Photographs were taken.) ADM arrived at the facility at approximately 10:20am with a tape measure. ADM stated he doesn't know why the sliding window screen keeps getting broken.

While LPA was measuring facility water temperature at approximately 9:39am, inside bathroom #1, LPA opened the cabinet below the sink as the water was running. LPA observed cleaning chemicals such as "Fabuloso" accessible to residents in care. (Photographs were taken.)


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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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: CARRANZA #1
FACILITY NUMBER: 435200432
VISIT DATE: 01/11/2024
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Fire extinguisher was serviced in July 12, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by AA, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on January 3, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff (S1) and 2 residents (R1-R2).

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrative Assistant Ernie Manaois and a copy of the signed report & appeal rights were provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/11/2024 10:39 AM - It Cannot Be Edited


Created By: Manuel Monter On 01/11/2024 at 10:14 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: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 LPA's observation, there was cleaning solutions (Faboloso) underneath the bathroom sink, in bathroom #1. This bathroom is accessible to residents in care. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will ensure disinfectants, cleaning solutions and other items that could pose a danger to residents are stored where they would be inaccessible to residents in care. ADM stated he will send LPA plan by POC date, 1/18/2024.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, bedroom #2 does not have a window screen. The sliding doors in the Atrium open space also do not have a sliding door screen. The family living room also does not have a sliding screen as well. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will ensure all window screen shall be in good repair. ADM stated he will send plan to LPA by POC date, 1/18/2024
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 Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
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