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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201046
Report Date: 05/31/2023
Date Signed: 06/01/2023 08:05:05 AM

Document Has Been Signed on 06/01/2023 08:05 AM - 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:LASSENPARK RESIDENTIAL HALL(RH)FACILITY NUMBER:
435201046
ADMINISTRATOR:VALIN, AMOR & VIRGILFACILITY TYPE:
735
ADDRESS:364 LASSENPARK CIRCLETELEPHONE:
(408) 227-1129
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 5DATE:
05/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Virgil ValinTIME COMPLETED:
01:26 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Virgil Valin. Staff Erlinda Asuncion (EA) and Arlene Esteban (AE) and 5 residents (R1 - R5) were observed in the facility.

LPA checked 5 resident files and 2 staff files.

LPA toured the facility inside out with ADM. Living room, kitchen, dinning room and two restrooms were inspected. Trash cans were observed with covers. Paper towels were observed with holders. Three shared resident bedrooms, and laundry room were inspected. One staff live-in room was observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, and knives closet were observed locked. Cleaning products under the sink in the kitchen were observed unlocked. Room temperature was at 70 degree F, and hot water temperature was at 111 degree F in facility. Fire extinguisher was serviced on 12/7/2022.

The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors and carbon monoxide detectors were tested by ADM, and were found out of battery. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Some deficiencies were found. LIC809-D and Appeal Rights were attached. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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 3
Document Has Been Signed on 06/01/2023 08:05 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 05/31/2023 at 12:18 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: LASSENPARK RESIDENTIAL HALL(RH)
FACILITY NUMBER: 435201046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 smoke detectors and carbon monoxide detectors were observed expired batteries, the licensee did not comply with the section cited above which poses/posed a potential safety risk to persons in care.
POC Due Date: 06/07/2023
Plan of Correction
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Administrator agreed to submit the Plan of Correction by the POC due date to change the batteries of the smoke detectors and carbon monoxide detectors, and to conduct weekly check for the batteries.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, gnats were observed around the garbage cans placed at the side yard by the building, the licensee did not comply with the section cited above which poses/posed a potential health risk to persons in care.
POC Due Date: 06/07/2023
Plan of Correction
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Administrator agreed to submit a Plan of Correction by the POC 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/01/2023 08:05 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 05/31/2023 at 12:42 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: LASSENPARK RESIDENTIAL HALL(RH)
FACILITY NUMBER: 435201046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
80088 Furniture, Fixtures, 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 facility window screens were either missing or not in goof repair, the licensee did not comply with the section cited above which poses/posed a potential health risk to persons in care.
POC Due Date: 06/07/2023
Plan of Correction
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Administrator agreed to submit a Plan of Correction to CCL by the POC due date.
Type B
Section Cited
CCR
80087(b)
80087 Building and Grounds (g) Disinfectants, cleaning solutions, poison, 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 cleaning products in kitchen were observed unlocked, the licensee did not comply with the section cited above which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 06/07/2023
Plan of Correction
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Administrator agreed to submit the Plan of Correction by the POC 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023


LIC809 (FAS) - (06/04)
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