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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200831
Report Date: 05/14/2025
Date Signed: 05/14/2025 07:31:44 PM

Document Has Been Signed on 05/14/2025 07:31 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:TWELVEACRES-BRAEBURN HOMEFACILITY NUMBER:
435200831
ADMINISTRATOR/
DIRECTOR:		AMY HELLYERFACILITY TYPE:
735
ADDRESS:3950 BRAEBURN COURTTELEPHONE:
(408) 984-7237
CITY:SAN JOSESTATE: CAZIP CODE:
95130
CAPACITY: 6CENSUS: 4DATE:
05/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Elizabeth Macharia and Amy HellyerTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, including detached storage shed in backyard. No accessible bodies of water or fire safety hazards are observed. There are 2 private bedrooms, a large shared bedroom, a vacant bedroom, two private bathrooms, a common bathroom, living room, and kitchen. In the 2 car garage, there is a washer and dryer, and storage cabinets. PPE and food supplies are adequate. Toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Soap and paper towels are present in bathrooms and kitchen sink. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 4 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as other staff records. Elizabeth Macharia is a certified ARF administrator (x 3/26) that oversees facility operations. Client records are reviewed. All residents are over the age of 60. Facility has an approved medical waiver to practice Christian Science, and does not handle medications, nor is required to maintain medical assessments for clients and staff.

The following forms/information are requested to be submitted to CCLD BY 5/28/25:
• proof of current surety bonding
• LIC 500 Personnel Report
• LIC 309 Administrative Organization
• LIC 308 Designation of Administrative Responsiblity
• Facility sketch, including dimensions
- LIC610D Emergency Disaster Plan (9 page, signed and dated)

Deficiencies of the California Code of Regulations, Title 22, Division 6, are cited on following pages. See also Technical Advisory Notes--3 pages.
NAME OF LICENSING PROGRAM MANAGER: Cowan April
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2025
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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Document Has Been Signed on 05/14/2025 07:31 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/14/2025 at 06:28 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: TWELVEACRES-BRAEBURN HOME
FACILITY NUMBER: 435200831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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, as hot water temperature is tested at 129 degrees in common bathroom. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
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Hot water temperature to be lowered and maintained between 105 and 120 degrees. Proof of correction to be sent to CCLD BY DUE DATE
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff records, the licensee did not comply with the section cited above in 1 out of 6 staff records reviewed, which poses an immediate health, safety or personal rights risk to persons in care.
- Staff #6 provides client care, but does not maintain criminal record clearance and association with facility. He is employed by a caregiver agency.
POC Due Date: 05/15/2025
Plan of Correction
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Criminal record clearance for staff #6 will be associated to this facility. Proof of correction to be sent to CCLD BY DUE 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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/14/2025 07:31 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/14/2025 at 06:44 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: TWELVEACRES-BRAEBURN HOME
FACILITY NUMBER: 435200831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(1)
PERSONAL RIGHTS
...Each client shall have personal rights which include, but are not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.


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, as video surveillance device is installed in 1 out of 3 client rooms, which poses an immediate health, safety or personal rights risk to persons in care.
Video monitoring device is observed in room of client #3, and base unit is located on office desk of staff.
POC Due Date: 05/14/2025
Plan of Correction
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Video monitor was removed and uninstalled in LPA's presence. Deficiency corrected and cleared.
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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2025 07:31 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/14/2025 at 07:02 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: TWELVEACRES-BRAEBURN HOME
FACILITY NUMBER: 435200831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4
ACCEPTANCE AND RETENTION LIMITATIONS
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of client records, the licensee did not comply with the section cited above, as all residents are over the age of 60. This poses a /posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2025
Plan of Correction
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Plan of correction to be submitted to CCLD BY DUE DATE, which may include exception requests and supportive documentation--appraisal, needs and services plans, letters of consent from responsible parties.
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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2025


LIC809 (FAS) - (06/04)
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