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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201149
Report Date: 08/23/2024
Date Signed: 08/23/2024 06:04:10 PM

Document Has Been Signed on 08/23/2024 06:04 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:BAYMILL CARE HOME IIFACILITY NUMBER:
435201149
ADMINISTRATOR/
DIRECTOR:		LOLITA BAUTISTAFACILITY TYPE:
735
ADDRESS:2065 DANDERHALL WAYTELEPHONE:
(408) 440-0433
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Administrator Lolita BautistaTIME VISIT/
INSPECTION COMPLETED:
06:05 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter conducted an unannounced annual inspection visit, and met with Staff S1. LPAs observed 6 residents and 2 staff. LPAs explained the purpose of the visit. ADM arrived at approximately 4:00 PM.

LPAs toured the facility inside out with Staff S1 Victoria Lauder which included the Living room, kitchen, dining room, 2 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected.

While touring the kitchen, LPAs observed 3 sticky cockroach traps on the kitchen counter with insects trapped inside. LPAs observed one of the traps close to the stove and a bowl of fruits. Facility staff removed the traps during LPAs visit. ADM stated she had already hired a pest control company to spray for the pests. ADM stated she would provide receipts from the pest control company to LPA.

While touring the backyard of the facility, LPAs observed a red wooden deck. As LPAs stepped onto deck, some wooden planks sank down when stepped on. LPAs continued to tour backyard, and observed the fence in the backyard had missing planks, which created an opening to the neighbors yard. (photographs were taken). As LPAs observed the fire emergency exits, emergency exit closest to the garage was obstructed by 1 trash can, 1 plastic container and 1 recycling bin (photographs were taken). LPAs also observed bedroom closest to the garage was missing a window screen. LPAs also observed the kitchen window was missing its screen.


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SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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 4
Document Has Been Signed on 08/23/2024 06:04 PM - It Cannot Be Edited


Created By: Marcella Tarin On 08/23/2024 at 05:18 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: BAYMILL CARE HOME II
FACILITY NUMBER: 435201149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
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.

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. While touring the backyard of the facility, LPA observed several wooden planks in the red deck would sink when stepped on. LPA's also observed the backyard near the red wooden deck, had missing planks that had an opening to the neighbor's backyard. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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ADM stated her handy man will fix it. ADM stated she will send LPA photo documentation showing it has been fixed. ADM stated she will send the written plan of correction to LPA by POC date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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. LPA's observed emergency exit closest to the garage was obstructed by 1 trash can, 1 plastic container and 1 recycling bin which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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ADM removed the obstructions during LPA's visit. ADM stated she will send a letter of understanding regarding the regulation, to LPA by POC 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:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/23/2024 06:04 PM - It Cannot Be Edited


Created By: Marcella Tarin On 08/23/2024 at 05:18 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: BAYMILL CARE HOME II
FACILITY NUMBER: 435201149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

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. LPAs observed bedroom closest to the garage was missing a window screen. LPAs also observed the kitchen window was missing its screen. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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ADM stated she will send photo documentation showing the window screens have been placed. ADM stated she will also send a letter of understanding regarding the regulation, to LPA by POC date.
Type B
Section Cited
CCR
80076(a)(15)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (15) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPAs observed 3 sticky cockroach traps on the kitchen counter with insects trapped inside. LPAs observed one of the traps close to the stove and a bowl of fruits. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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ADM removed the traps in the counter during LPA's visit. ADM stated she will send a written letter of understanding regarding the regulation and send to LPA by POC 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:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: BAYMILL CARE HOME II
FACILITY NUMBER: 435201149
VISIT DATE: 08/23/2024
NARRATIVE
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Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 105 degrees F in both resident bathrooms.

Fire extinguisher was serviced on 10/25/2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 04/22/2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPAs reviewed 3 PNI records. LPA conducted interviews with 2 staff.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Lolita Bautista and a copy of the signed report was provided. Appeal rights were provided.

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END OF REPORT.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4