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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200964
Report Date: 10/21/2023
Date Signed: 10/22/2023 07:41:34 PM

Document Has Been Signed on 10/22/2023 07:41 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:MERTZ CARE HOME IVFACILITY NUMBER:
435200964
ADMINISTRATOR:MERTZ, ELVIRAFACILITY TYPE:
735
ADDRESS:2591 BOREN DRIVETELEPHONE:
(408) 947-0825
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
10/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Staff Rogeline JimenizTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff member Rogeline Jimeniz (S1). (LPA observed 5 staff including S1, during facility visit)

LPA toured the facility inside out with S1 which included; the Living room, kitchen, dinning room, one halfway restroom and 3 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 78 degree F. During visit, S1 stated the facility had a partial power outage in the morning. The facility had a partial power outage and some portions of the facility did not have electricity. S1 stated an electrician was already called and would arrive later today. LPA attempted to measure facility water temperature, but due to electricity being out, the electric water heater was not working, and hot water temperature could not be measured during the visit.

Fire extinguisher was serviced in January 18, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on July 22, 2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. 3 resident P & I records were reviewed. LPA conducted interviews with 3 staff (S1 to S3) and 3 residents (R1-R3).

No deficiencies cited during today's visit. This report was reviewed with staff member Rogeline Jimeniz and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2023
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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