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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200432
Report Date: 01/03/2025
Date Signed: 01/03/2025 12:03:45 PM

Document Has Been Signed on 01/03/2025 12:03 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:CARRANZA #1FACILITY NUMBER:
435200432
ADMINISTRATOR/
DIRECTOR:		CARRANZA, EDUARDOFACILITY TYPE:
735
ADDRESS:2052 LADDIE WAYTELEPHONE:
(408) 809-4715
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:52 AM
MET WITH:Administrator Eduardo CarranzaTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Eduardo Carranza. During the visit, LPA observed 5 residents and 1 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. LPA toured the facility garage, being used as a storage space/laundry area. There was no obstruction to block the walkways.

While touring resident bedroom 4, LPA observed a hole in the residents wall, next to the residents closet. (Photograph was taken.) While touring the hallway, LPA observed a light fixture, when directly exiting bathroom #1, LPA observed, inside the light fixture, dead insects. (Photographs were taken.) While touring resident bedroom #1, as LPA entered, there was an odor inside the bedroom.

LPA toured the backyard. LPA observed, 2 shopping carts and a mattress & wooden bed frame. LPA also observed the fence closest to the living room, was leaning. (Photographs were taken.)

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 73 degrees F, and hot water temperature was measured at 115 degrees F in both resident bathrooms.


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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 01/03/2025
NARRATIVE
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Fire extinguisher was serviced in July 24, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 23, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA requested to review R3's Needs and services plan. LPA observed the R3's needs and Services plan was dated May 8, 2024, but did not have any information, but was signed. (Photograph was taken.). LPA asked ADM if he had a needs and services plan with information. ADM stated the doctor/social worker was supposed to fill it out. LPA explained to ADM, that a residents Needs and Services plan must be develop in collaboration with the following individuals: the Administrator, the resident, the residents responsible party, while cross referencing the residents records, such as their physicians report.

LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 1 residents.

Deficiencies cited during today's visit. This report was reviewed with Administrator Eduardo Carranza and a copy of the signed report was provided. Appeal Rights were Provided.

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

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
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Document Has Been Signed on 01/03/2025 12:03 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/03/2025 at 11:34 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: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above. LPA observed resident bedroom 4 had a hole next to the residents closet. LPA observed a light fixture, when directly exiting bathroom #1, had dead insects inside. LPA noted there was an odor inside resident bedroom 1. LPA observed in the backyard 2 shopping carts & a mattress & Frame, and the fence closest to the living room, was leaning. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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ADM stated he will send a written plan of action on how he will address; the hole in resident bedroom 4, the light fixture when directly exiting bathroom 1, the odor in resident bedroom 1, the two shopping carts and mattress & wooden frame and the leaning fence in the backyard. ADM stated he will send the written plan of action to LPA by POC date, January 10, 2025.
Type B
Section Cited
CCR
85068.2(b)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above. LPA observed the R3's needs and Services plan was dated May 8, 2024, but did not have any information, but was signed. . LPA asked ADM if he had a needs and services plan with information. ADM stated the doctor/social worker was supposed to fill it out. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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ADM stated he will complete a written needs and Services plan for resident R3. ADM stated he will send LPA a copy of the completed needs and Services plan to LPA by POC date, 01/10/2025.
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: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


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