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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201034
Report Date: 08/17/2023
Date Signed: 08/17/2023 04:53:47 PM

Document Has Been Signed on 08/17/2023 04:53 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ESR MANORFACILITY NUMBER:
435201034
ADMINISTRATOR:REYES, ELIZABETHFACILITY TYPE:
735
ADDRESS:602 NOVAK DRIVETELEPHONE:
(408) 926-0859
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
08/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Senen SemanaTIME COMPLETED:
04:22 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Senen Semana. LPA checked 5 residents files and 5 staff files. One of the staff does not have health screening form. HM stated the facility will have the staff to complete the health screening check.

LPA toured the facility inside out with HM. License and Personal Rights posters were observed at the main entrance. Living room, family room/dining room, kitchen, 3 shared resident bedrooms, 2 staff room, 2 resident restrooms, 1 staff restroom and laundry room were inspected. Nonskid pads were observed in the restrooms. Cloth towels were observed in the restrooms and kitchen. Medication closet, detergent closet, and knives closet were observed locked. One knife was observed left at kitchen counter, HM stated she just went to open the door for LPA. All the bedrooms were observed with window screens. First Aid kit was observed in facility. The kitchen window was observed without screen. The battery powered lighting for emergency lighting was observed ran out of battery

Two day perishable food supplies and Seven day nonperishable food supplies were observed sufficient. Room temperature was observed at 83 degree F. Hot water temperature was observed at 106 degree F. Refrigerator temperature was observed at 40 degree F. Freezer temperature was observed at 0 degree F.

Fire extinguisher was serviced on 05/08/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, one of the carbon monoxide detectors ran out of battery. LPA toured backyard with HM. A storage room was observed at the backyard. There is no obstruction to block exit at the backyard.

Exit interview was conducted with HM. LIC809-D and Appeal Rights were attached. The report was provided to HM for signature. A copy of the report was provided to HM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 08/17/2023 04:53 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 08/17/2023 at 03:07 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: ESR MANOR
FACILITY NUMBER: 435201034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 in one of the carbon monoxide detector was observed ran out of battery which poses an immediate safety risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee to submit a plan of correction by the POC due date to change the battery of the carbon monoxide detector.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 that one knife was observed left at the kitchen counter unattended which poses an immediate safety risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee to submit a plan of correction by the POC due date to provide training to staff that the knife should be locked immediately after use.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/17/2023 04:53 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 08/17/2023 at 03:07 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: ESR MANOR
FACILITY NUMBER: 435201034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 that the kitchen window was observed without screen which poses/posed a potential health risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Licensee to submit a plan of correction by the POC due date to add screen to the kitchen window.
Type B
Section Cited
CCR
85088(e)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff.

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 that the battery powered lighting for emergency lighting was observed ran out of battery which poses/posed a potential safety risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee to submit a plan of correction by the POC due date to change the batteries of the battery powered lighting for emergency lighting.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/17/2023 04:53 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 08/17/2023 at 03:07 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: ESR MANOR
FACILITY NUMBER: 435201034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above that one of the staff was observed without health screening form which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Licensee to submit a plan of correction by the POC due date to have the staff to complete the health screening checking.
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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5