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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200459
Report Date: 11/26/2024
Date Signed: 11/26/2024 02:28:21 PM

Document Has Been Signed on 11/26/2024 02:28 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:HOMELIFE RESIDENTIAL CAREFACILITY NUMBER:
435200459
ADMINISTRATOR/
DIRECTOR:		JAVIER, JULIUS ERVINFACILITY TYPE:
735
ADDRESS:367 FONTANELLE DRIVETELEPHONE:
(408) 578-6257
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 5DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Audrey SalvadorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with with Audrey Salvador, Administrator.

During visit, LPA toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least three days and a non-perishable food supply of at least seven days. LPA observed there to be locked storage areas for sharp objects and medications. LPA reviewed the first aid kit and found it to be complete. The facility Earthquake Drill Log indicates the last drill was conducted on 10/23/2024.

LPA observed the garage area and observed there to be locked storage areas for cleaning supplies. LPA toured the living room area and three out of three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. LPA tested the smoke detectors in the kitchen, hallway, and three out of three resident bedrooms, and all smoke detectors functioned properly when tested. LPA tested the carbon monoxide detector and it functioned properly when tested. LPA toured the outside area and found it to be clear of obstructions. LPA toured 1 out of 1 resident bathrooms and found it to have non-slip mats, working lights, and available soap and paper towels. The water temperature in the bathroom sink measured at 119 F.

LPA reviewed the personal and incidental money logs for residents R1-R5. R1's Personal and Incidental Money Log showed a balance of $484.45, but R1's money pouch only had $415.55. Resident 2's Personal and Incidental Money Log showed a balance of $4,530.55, but R2's money pouch only had $4,444.12. LPA reviewed the Resident Records and Centrally Stored Medication and Destruction Records for R1-R5 and 5 staff records and found them to be complete. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information. This report was reviewed with Administrator Audrey Salvador and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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Document Has Been Signed on 11/26/2024 02:28 PM - It Cannot Be Edited


Created By: David Marrufo On 11/26/2024 at 02:07 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: HOMELIFE RESIDENTIAL CARE
FACILITY NUMBER: 435200459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(1)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 2 out of 5 resident Personal and Incidental Money Logs, which had balances which were greater than the money in the resident money pouches, which poses personal rights risk to persons in care.
POC Due Date: 12/03/2024
Plan of Correction
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Licensee agrees to conduct an in-service training with staff on how staff will ensure that accurate records of accounts of resident cash resources entrusted to staff are maintained. Licensee shall also ensure that all residents with missing money are made whole *During visit, Administrator added missing money to each of the two resident money pouches that was missing money.*
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:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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