435200733-10-9-2025-26-AS-CKAI-DMAVWU-20251009164831

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200733
Report Date: 10/09/2025
Date Signed: 10/09/2025 04:48:43 PM

Document Has Been Signed on 10/09/2025 04:48 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:	NIKKO'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	435200733
ADMINISTRATOR/ DIRECTOR:	SEDIGH, MALOU		FACILITY TYPE:	735
ADDRESS:	13540 COLUMBET AVE		TELEPHONE:	(408) 683-4354
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY: 6		CENSUS: 5	DATE:	10/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:20 PM
MET WITH:	Jhanelle Guico, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:55 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) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Administrator (ADM), Jhanelle Guico. During visit, LPA toured the facility with ADM to include the dining room, kitchen, living room, 5 resident bedrooms, 3 bathrooms, activity/exercise room, 3 staff bedrooms, laundry room, and exterior. All fire exit routes were free and clear of obstruction. 5 residents were arriving home from day program. 5 staff members present who were fingerprint cleared and associated to the facility. There are 5 live-in staff who are fingerprint cleared and associated to the facility. Facility temperature maintained at 70 degrees F. Fire extinguisher last serviced on 05/02/2025. Carbon monoxide observed operable and placed in the living room area. Due to the size of the house, LPA advised to place a carbon monoxide detector in each hallway where the residents are sleeping. Facility is equipped with fire alarms and sprinkler system. ADM states a plan to contact the fire department to inspect the alarm and sprinkler system to ensure they are still in working condition. The facility screen windows were observed to be in good repair. The washer and dryer located in the laundry room observed in working condition. Laundry soap and cleaning supplies are locked. LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete and is accessible to staff. Resident bedrooms equipped with beds, linens, night stands, closet space, and adequate lighting. Resident bedroom doors are equipped with operable door alarms. Bathroom is equipped with grab bars and hygiene products. Page 1 of 2.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

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: NIKKO'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 435200733
	VISIT DATE: 10/09/2025

NARRATIVE

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Bathroom hot water temperatures were measured on the left side of the house and right side of the house, which measured between 113.3 - 117.1 degrees F. Sharp objects, chemicals and disinfectants observed locked in a kitchen cabinet. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 40 degrees F. Freezer temperature maintained at 12 degrees F. A type A deficiency was cited Section 85076(d)(2) wherein the freezer temperature was measured at 12 degrees F.

In the backyard, LPA observed the area to be well maintained. The 4 inoperable vehicles that were stored in the exterior that was observed during last year's annual inspection were all removed. All the vehicles parked on property were in working condition. LPA did not observe piles of dry woods, old furniture covered with tarp at the side of the building, overgrown grass and dry bushes by the fence at left side of the property, and outdoor kitchen area under the tree. Administrator states all these items were removed.

3 resident files were reviewed and observed complete and up-to-date. 3 resident's centrally stored medication and records were reviewed and no issues were noted. 3 resident's P&I money was inspected and counted with the ADM and all money was accounted for. LPA observed the resident's admission agreement on file is with the consumer, SARC, and facility. LPA advised to ensure the facility has their own admission agreement in the resident's file, between the resident and facility. ADM stated understanding. 4 staff files were reviewed and observed complete. 4 staff has an active first aid certification, fingerprint clearance, health screening, TB result, and training for 2025.

Facility has an emergency disaster plan. Emergency drills are completed quarterly and the last drills were completed in July and August 2025. Facility has 1 flashlight. LPA advised the ADM to ensure there is enough emergency lighting for all the residents and staff in case of a power outage. A technical violation was issued.

Documents were requested by 10/16/2025 to update the facility file: Administrator certificate, LIC500, LIC308, Lease Agreement, Emergency disaster plan. During visit, LPA obtained a copy of the facility sketch. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note provided. This report was reviewed with Administrator, Jhanelle Guico and a copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/09/2025 04:48 PM - It Cannot Be Edited

Created By: Christine Kabariti On 10/09/2025 at 04:35 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: NIKKO'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 435200733
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

85076(d)(2)

Food Service

(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (-17.7 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review the licensee did not comply with the section cited above in wherein the freezer temperature was observed maintained at 12 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2025
	Plan of Correction
1 2 3 4	Administrator states that a technician will come tonight to check the freezer. Administrator states that if they are unable to lower the freezer temperature, they will plan to purchase a new freezer. Administrator states to send a written update of the plan after the technician inspects the freezer to the Department's general email box by 10/10/2025.

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.

	Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:

	Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC809 (FAS) - (06/04)

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