435201156-10-13-2025-26-AS-MYAZ-DMF265-20251013170634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201156
Report Date: 10/13/2025
Date Signed: 10/13/2025 05:06:54 PM

Document Has Been Signed on 10/13/2025 05:06 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:	GLEN ELM CARE HOME, INC		FACILITY NUMBER:	435201156
ADMINISTRATOR/ DIRECTOR:	YOLANDA GAOIRAN		FACILITY TYPE:	735
ADDRESS:	2487 GLEN ELM WAY		TELEPHONE:	(408) 687-6979
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY: 6		CENSUS: 6	DATE:	10/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:05 PM
MET WITH:	Ernesto Rafon, caregiver		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Ernesto Rafon, Caregiver, ADM was not at the facility and contacted by phone and stated caregiver can sign on her bahalf. LPA announced the purpose of the visit. LPA observed 5 residents in there rooms. During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications. LPA observed unlocked drawer with knives as well as unlocked cabinet under sink with toxics accessible to residents in care. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. Caregiver tested the smoke detector and found the smoke detector to not function properly when tested. LPA toured one resident bathroom. Resident bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sink measured with thermometer at 122 degrees F. ADM was advised water temperature to range from 105-120 degrees F. During tour LPA observed unlocked cabinet that contained toxics under bathroom sink accessible to residents in care. During visit staff locked cabinet under bathroom sink but were not able to lock drawer of knives in kitchen and moved knives under kitchen sink that has a functioning lock. page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: GLEN ELM CARE HOME, INC	FACILITY NUMBER: 435201156
	VISIT DATE: 10/13/2025

NARRATIVE

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LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 08/22/25. LPA reviewed Fire and Earthquake log last fire drill was conducted on 10/12/25 and Earthquake drill was conducted 09/7/25

LPA reviewed resident records for 2 residents. LPA reviewed 2 staff records. ADM and LPA reviewed centrally stored medication record for 2 residents and P and I money was reviewed for 2 residents

Deficiency was cited as per California Code of Regulations Title 22. and a technical violation was given. This report was reviewed with Ernesto Rafon, on ADMs behalf. Caregiver and a copy of this report and appeal rights were provided.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/13/2025 05:06 PM - It Cannot Be Edited

Created By: Marcela Yanez On 10/13/2025 at 04:48 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: GLEN ELM CARE HOME, INC	FACILITY NUMBER: 435201156
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)(1)

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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview , the licensee did not comply with the section cited above by having an unlocked drawer that contained knives in the kitchen and an unlocked cabinet under sink in resident bathroom that contained toxics which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2025
	Plan of Correction
1 2 3 4	ADM will submit a letter of understanding of the regulation and will have in-service training for staff, and place a new lock on drawer for knives and will submit to LPA via email by POC due date 10/14/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Marcela Yanez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/13/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025

LIC809 (FAS) - (06/04)

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