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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201046
Report Date: 04/30/2024
Date Signed: 04/30/2024 04:38:26 PM

Document Has Been Signed on 04/30/2024 04:38 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:LASSENPARK RESIDENTIAL HALL(RH)FACILITY NUMBER:
435201046
ADMINISTRATOR/
DIRECTOR:		VALIN, AMOR & VIRGILFACILITY TYPE:
735
ADDRESS:364 LASSENPARK CIRCLETELEPHONE:
(408) 227-1129
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 5DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Virgil ValinTIME VISIT/
INSPECTION COMPLETED:
04:35 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. 2 staff and 5 residents (R1 - R5) were observed in the facility. License, personal right posters and ADM certificate were observed in the facility.

LPA checked 3 resident files and 3 staff files.

LPA toured the facility inside out with ADM. Living room, kitchen, dinning room and two restrooms were inspected. Three shared resident bedrooms, and laundry room were inspected. Two staff live-in rooms were observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, dish washing product closet, and knives closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 111 degree F in facility. The temperature of the refrigerator was at 37 degree F, and the temperature of the freezer was at 0 degree F. Fire extinguisher was serviced on 12/8/2023.

First aid box and flash lights were observed in the facility.

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 working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

The last time the facility conducted the emergency and fire drill was on 12/04/2023.

Deficiencies noted today. See LIC809-D. 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: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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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Document Has Been Signed on 04/30/2024 04:38 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 04/30/2024 at 02:32 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
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. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 that no night light was observed in th efacility which poses/posed a potential safety risk to persons in care.
POC Due Date: 05/07/2024
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due date to install night lights in the facility.
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: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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