<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200551
Report Date: 03/29/2024
Date Signed: 03/29/2024 04:18:01 PM

Document Has Been Signed on 03/29/2024 04:18 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:SAINT DOMINIC MANORFACILITY NUMBER:
435200551
ADMINISTRATOR:NAVARRO, ILUMINADAFACILITY TYPE:
735
ADDRESS:1828 ROCHELLE DRIVETELEPHONE:
(408) 371-2698
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 4DATE:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH: ILUMINADA NAVARROTIME COMPLETED:
12:13 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Iluminada Navarro and house manager Remil Navaro (HM).

2 residents and 2 staff were observed at the facility.

LPA reviewed 2 residents files and 2 staff files.

LPA toured the facility inside out with HM. License, Administrator Certificate, and personal rights posters were observed in the facility. Living room, kitchen, dinning room and two restrooms were inspected. Grab bars and non-skid mats were observed in the restrooms. 5 single resident bedrooms, 1 staff live-in room, laundry room, and garage were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, and cleaning product closet were observed locked. Knives closet was observed not locked. Room temperature was at 69 degree F, and hot water temperature was at 111 degree F in facility. The temperature of the refrigerator was at 37 degree F, and the temperature of the freezer was at 0 degree F.

First box, flash light, and night lights were observed in the facility.

Fire extinguisher was serviced on 05/4/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Front yard and backyard were inspected. There was no obstruction to block the walkways. The last time the facility conducted the emergency and fire alarm drill was on 12/18/2023.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2024
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 3
Document Has Been Signed on 03/29/2024 04:18 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 03/29/2024 at 11:50 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: SAINT DOMINIC MANOR
FACILITY NUMBER: 435200551

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that the knives closet was observed unlocked which poses an immediate health, safety risk to persons in care.
POC Due Date: 03/30/2024
Plan of Correction
1
2
3
4
ADM stated to send a plan of correction by the POC due date to lock the knives closet.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/29/2024 04:18 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 03/29/2024 at 11:50 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: SAINT DOMINIC MANOR
FACILITY NUMBER: 435200551

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that one staff does not have health screen form which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
ADM stated to send a plan of correction by the POC due date to have the staff to complete the health screen form.
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that the staff files are incomplete which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
ADM stated to send a plan of correction by the POC due date to maintain the staff files complete and up to date.
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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3