435200551-4-24-2025-26-AS-MPAA-DG2N86-20250424101348

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200551
Report Date: 04/23/2025
Date Signed: 04/24/2025 10:14:19 AM

Document Has Been Signed on 04/24/2025 10:14 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:	SAINT DOMINIC MANOR		FACILITY NUMBER:	435200551
ADMINISTRATOR/ DIRECTOR:	REMIL NAVARRO		FACILITY TYPE:	735
ADDRESS:	1828 ROCHELLE DRIVE		TELEPHONE:	(408) 371-2698
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY: 6		CENSUS: 3	DATE:	04/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Remil Navarro-Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 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) Maria (Mita) Partoza conducted an unannounced required 1 year inspection visit, and met with Administrator (ADM) Remil Navarro and stated the purpose of the visit. The facility is licensed to serve 18 through 59 who has mental disability. The facility can accommodate 6 ambulatory. LPA observed 1 staff and 3 resident during the visit. LPA toured the facility inside and outside including the living room, kitchen, dining room, 2 restrooms, 4 resident bedrooms and staff room, backyard and side emergency exits. LPA observed hallways and walkways to be free from obstructions. Residents room has ample storage for their personal belonging. LPA inspected food storage and observed 2 days of perishable and 7 days of nonperishable food supplies. LPA observed the medication, chemicals and knives were locked and not easily accessible to residents. The room temperature is at 70 degrees F, and hot water temperature was measured at 113.7 to 114 degrees F. Fire extinguisher was serviced in June 27,2924. The facility is equipped with carbon monoxide and smoke detectors and were observed to be in good working condition when tested. page 1 of 2 see LIC809C

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: SAINT DOMINIC MANOR	FACILITY NUMBER: 435200551
	VISIT DATE: 04/23/2025

NARRATIVE

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LPA observed facility first aid kit were complete and were accessible to staff. LPA reviewed 3 residents record and 1 staff records. Based on review 2 out of 3 resident's record does not have an updated needs and service plan. The facility conducted disaster training on 1/10/2025.

LPA provided a technical advisory and suggested to administrator to avail of the Technical Support Program (TSP) services provided by the Department. Technical advisory was provided for the daily upkeep and maintenance of the surfaces in the resident's room, living, dining, bathroom, kitchen and exterior.

Deficiencies was cited during today's visit based on California Code of Regulation (CCR) Title 22 85068.3(a). An Exit interview was conducted with administrator Remil Navarro and a copy of the report and appeals rights was provided.

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end of report

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/24/2025 10:14 AM - It Cannot Be Edited

Created By: Maria Partoza On 04/23/2025 at 11:55 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: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.3(a)

Modifications to Needs and Services Plan

(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. 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 by not updating 2 out of 3 resident's (R2 & R3) needs and services plan as frequently as necessary to ensure it's accuracy to document significant occurences and changes in the client's physical and social function which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2025
	Plan of Correction
1 2 3 4	ADM stated the R2 and R3s needs and services plan will be updated and a written plan of correction will be submitted to LPA by the due date. ADM will submit a memorandum of understanding based on the above cited deficiency.

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.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

LIC809 (FAS) - (06/04)

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