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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200664
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:01:48 PM

Document Has Been Signed on 09/10/2024 04:01 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:MARIA'S HOMEFACILITY NUMBER:
435200664
ADMINISTRATOR/
DIRECTOR:		ROY, MARIA G.FACILITY TYPE:
735
ADDRESS:1038 RAWLINGS DRIVETELEPHONE:
(408) 622-5598
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 5DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:27 AM
MET WITH:Rubenita SandovalTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Rubenita Sandoval.

LPA observed 3 staff and 1 resident in the facility. 4 residents went to day program.

LPA reviewed 3 resident files and 3 staff files.

LPA toured the facility inside out with ADM. License, ADM Certificate, and Personal Rights posters were observed in the facility. Family room, kitchen, dinning room and three restrooms were inspected. Bar and non skid mats were observed in the restroom. 4 single resident bedrooms, 1 shared resident bedroom and laundry room were inspected. One office was observed in the facility. Two bedrooms were observed added in the office. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 72 degree F, and hot water temperature was at 119 degree F in facility. The temperature of the freezer was at -20 degree F, and the temperature of the refrigerator was at 25 degree F.

Fire extinguisher was serviced on 01/11/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. Three storage rooms were observed at the backyard.

First aid box, night lights, and flash lights were observed in the facility. The last time the facility conducted the fire drill was on 9/8/2024. Deficiency noted today. See LIC 809-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: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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 09/10/2024 04:01 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 09/10/2024 at 11:58 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: MARIA'S HOME
FACILITY NUMBER: 435200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that 2 bedrooms were observed added in the office that were not specified in the sketch, Administrator stated he/she has document to show it was approved but was unable to show the document during the inspection. That poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
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Administrator stated to understand the regulations and to submit a plan of correction by the POC due date to fix the issue.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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