435200942-6-19-2026-26-AS-MMOR-DV7SH4-20260619135255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200942
Report Date: 06/19/2026
Date Signed: 06/19/2026 01:53:22 PM

Document Has Been Signed on 06/19/2026 01:53 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:	GYPSY HEIGHTS CARE HOME		FACILITY NUMBER:	435200942
ADMINISTRATOR/ DIRECTOR:	BUL-LALAYAO, JOYCELINE		FACILITY TYPE:	735
ADDRESS:	1642 GYPSY PLACE COURT		TELEPHONE:	(408) 223-2250
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY: 6		CENSUS: 6	DATE:	06/19/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:10 PM
MET WITH:	Administrator Joyceline Bul-lalayao		TIME VISIT/ INSPECTION COMPLETED:	02:00 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	On June 19, 2026, Licensing Program Analyst Manuel Monter conducted an unannounced case management - incident visit regarding an incident where a resident eloped from the facility. LPA met with Administrator Joyceline Bul-lalayao and explained the purpose of the visit. On June 8, 2026, the Department received an incident report (IR) regarding resident R1. The IR stated the following: on June 8, 2026, at 4:05am, resident R1 came out of his/her bedroom and sat on the couch. Staff member was cooking breakfast in the kitchen and told R1 that breakfast was not ready and to return to his/her bedroom. Staff member observed R1 entering his/her bedroom. At 4:15am, staff member heard two residents making noise in their room and went to check. That was when the staff member noticed the front door was open. Staff member checked every room and noticed R1 was not in his/her room and did not hear the door alarm chime. Staff member then went outside to look for R1 and found R1 in front of next door neighbors house and the police had just gotten there. On June 9, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator Joyceline Bul-lalayao, referred to as ADM. ADM stated she only knows what her staff reported to her. ADM stated the night of the elopement, there was 1 wake night staff. ADM stated R1 came out to the living room around 4:00am, and sat down on the couch. Staff S1 told him/her that he/she was still cooking and breakfast wasn’t ready. S1 had stated he/she had seen R1 return to his/her bedroom. S1 stated around 4:15am, he/she heard a noise coming from the residents bedrooms. S1 had observed that the front door was open. S1 had searched the home and didn’t find R1. S1 exited the facility and found R1 outside, found R1 in front of next door neighbors house and the police had just gotten there. Page 1 out of 3

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

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: GYPSY HEIGHTS CARE HOME	FACILITY NUMBER: 435200942
	VISIT DATE: 06/19/2026

NARRATIVE

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ADM stated resident R1 does have the behavior of attempting to leave the home during the day. ADM stated one of R1’s behaviors is he/she will try to exit, but staff will follow him/her and provide supervision.

On June 15, 2026, Licensing Program Analyst Manuel Monter interviewed staff S1. S1 stated the day of the elopement, he/she was preparing breakfast and R1 had gotten up and had sat in the couch in the living room around 4:00am. S1 stated he/she told R1 to go back to his/her room, because it was too early. S1 stated he/she assisted R1 back to his/her bedroom and R1 laid down. S1 stated he/she then went back to the kitchen. S1 stated when he finished with breakfast preparations (about 15 minutes later), he/she went to check on the residents and saw that the front door was open. S1 stated he/she then went to check to see if the residents were in their rooms. S1 stated R1 was not in his/her bed and he/she then ran to the front of the home. S1 stated he/she saw that R1 was next door, (to the right), with the police already with him/her. S1 stated he/she then went to get his/her back inside the facility.

S1 stated R1 does have history of wandering during the day. S1 stated staff is aware of this behavior and its occurring during the daytime. S1 stated when R1 is exit seeking, staff do redirect. LPA asked S1 if he heard the door alarm ring that night. S1 stated he/she isn’t sure. S1 stated he/she can’t recall.

On June 19, 2026, Licensing Program Analyst Manuel Monter interviewed witness W1. W1 stated on June 8, 2026, at 4:03am he/she was awoken due to R1 ringing the doorbell and attempting to open the door to his home. W1 he/she contacted 911 at 4:06am. W1 stated he/she did not observe staff members with R1. W1 stated when police arrived they re-directed R1 away from the home. W1 stated he observed the police walk towards Gypsy Heights care home.

The Department reviewed Resident R1’s Physician’s Report dated February 20, 2026. The report states R1 cannot leave the facility unassisted.

On June 8, 2026 at 4:08am, local law enforcement (LLE) was dispatched, regarding a report of a suspicious person ringing the door bell. LLE arrived and observed R1 appeared lost. LLE made contact at the residence next door and observed a staff who appeared to be looking for someone. LLE informed him/her of R1 being outside. Page 2 Out of 3.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

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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: GYPSY HEIGHTS CARE HOME	FACILITY NUMBER: 435200942
	VISIT DATE: 06/19/2026

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An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 wandering from the facility unsupervised.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Joyceline Bul-lalayao and a copy of the report and appeal rights were provided.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/19/2026 01:53 PM - It Cannot Be Edited

Created By: Manuel Monter On 06/19/2026 at 01:40 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: GYPSY HEIGHTS CARE HOME	FACILITY NUMBER: 435200942
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/20/2026 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidence by:	1 2 3 4 5 6 7	ADM stated she will send a letter of understanding regarding the regulation. ADM stated he will submit a plan of action on how she will ensure staff are meeting R1's supervision needs.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, on June 8, 2026, Resident R1 wandered from the facility unsupervised. R1's physican's report states R1 cannot leave the facility unassisted. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14	ADM stated she will send to LPA by POC due date June 20, 2026
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

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