435200924-9-22-2025-26-AS-CKAI-DLRV58-20250922160732

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200924
Report Date: 09/22/2025
Date Signed: 09/22/2025 04:07:39 PM

Document Has Been Signed on 09/22/2025 04:07 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:	GILROY ELDERLY CARE HOME		FACILITY NUMBER:	435200924
ADMINISTRATOR/ DIRECTOR:	CLARK, DINA		FACILITY TYPE:	740
ADDRESS:	415 LONDON DRIVE		TELEPHONE:	(408) 847-4645
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY: 6		CENSUS: 3	DATE:	09/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Dina Clark, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:15 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 inspection. LPA met with Administrator/Licensee, Dina Clark. During visit, LPA toured the facility to include the living room, kitchen, resident bedrooms, bathrooms, garage, and exterior. All fire exit routes were free and clear of obstruction. There was 1 staff to 3 residents. Facility staff present are fingerprint cleared and associated to the facility. As of today, there are no residents under hospice care. Facility temperature maintained at 77 degrees F. Kitchen supplied with at least 2 days worth of perishables and 7 days worth of non-perishable foods. LPA observed the facility has fresh fruits on the kitchen counter to include bananas, oranges, apples, cantaloupe, and watermelon. Refrigerator temperature maintained at 40 degrees F. Freezer temperature maintained at 0 degrees F. Sharp object, chemicals and disinfectants are locked and stored separately from the food supply. Lidded trash bin observed in the kitchen. At 2:15PM, the hot water temperature in the bathrooms were measured at 101.8 - 102 degrees F. During visit, licensee adjusted the hot water temperature. At 02:57PM, the hot water temperature in the bathrooms was measured at 105.8 degrees F. Resident bathroom equipped with a shower chair, grab bars, and non-slip mats. Resident bedrooms equipped with beds, linens, dresser, night stands, and adequate lighting. Sliding doors equipped with door alarms and observed clear of obstruction. SEE LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

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: GILROY ELDERLY CARE HOME	FACILITY NUMBER: 435200924
	VISIT DATE: 09/22/2025

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LPA reviewed 3 resident files contained an admission agreement, medical assessment, TB result, personal rights, consent forms, and updated and signed appraisal/needs and services plan. The appraisal/needs and services plan were observed signed and completed. LPA reviewed 3 staff files were reviewed and observed complete. 3 out of 3 staff has an active 1st aid certification, health screening, TB result, and personnel record. Staff are provided at least 20 hours of annual training to include topics of emergency preparedness, dementia/Alzheimer's, medications, and oxygen use. ADM states training is ongoing throughout the year. ADM states a plan to complete training on postural supports and restricted health conditions.

LPA observed the facility's prepared emergency supply which includes linens, non-perishable foods, emergency lighting, and a first aid kit. Facility has flashlights, lanterns, and batteries in case of an emergency. Fire extinguisher last serviced on 10/07/2024. Carbon monoxide present and observed operable. Facility has a large plastic bin filled with PPE supplies in the garage.

Licensee states the last emergency drill was completed on 07/07/2025, but Licensee was unable to find the document of the drill which includes the topics of the emergency covered, participants, and date of the drill. Licensee states on 07/07/2025 she remembers covering the topic of fire and fire failures. Licensee states to have remembered covering the emergency drills in January, March and July 2025 which are the same dates listed on the LIC610E, however thinks the document of the drills was either left in her other care facility or at home. Licensee will find the emergency drills documents and submit the documents to LPA Kabariti via email. A technical violation was provided.

Posters observed in the hallways to include but not limited to complaint poster, ombudsman poster, emergency disaster plan, facility license, personal rights, and COVID-19 related resources.

The following documents were obtained during visit to update the facility file: LIC500, liability insurance, and page 9 of the LIC610E.

No deficiencies were cited per California Code of Regulations, Title 22. Technical advisory was provided. This report was reviewed with Administrator/Licensee, Dina Clark and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

LIC809 (FAS) - (06/04)

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