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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201271
Report Date: 02/02/2024
Date Signed: 02/02/2024 11:03:33 AM

Document Has Been Signed on 02/02/2024 11:03 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MCLAUGHLIN MANORFACILITY NUMBER:
435201271
ADMINISTRATOR:JOYCELINE BUL-LALAYAOFACILITY TYPE:
735
ADDRESS:286 HERLONG AVENUETELEPHONE:
(408) 972-0562
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Joyceline Bul-lalayaoTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mita Partoza and Manuel Monter conducted an unannounced annual inspection to the facility. LPAs met administrator (ADM) Joyceline Bul-Lalayao and 2 staff.
All clients attends day program and were currently out of the facility.
Current census of the facility is 6 residents and 7 staff.

During visit, LPAs toured the facility to include the living room, dining room, kitchen, bedrooms, bathroom, garage, and backyard. 3 staff room was inspected, 2 bathroom were inspected. The bathroom hot water temperature was measured at 123.4F to 131.5F room temperature in the facility was at 68-75F. LPA observed the wall switch plate was broken, in the hallway bathroom across from resident bedroom #2. While touring the resident bedroom #1, LPA's observed blinds that were damaged.

LPA randomly reviewed 3 resident and 3 staff records including residents medication and P&I.
There is sufficient 2 day perishable and 7 days non-perishable food supply as required by regulations. Toiletries such toilet paper, paper towels, toothpaste are inspected and found to be sufficient. Toxic materials but not limited to laundry detergent and disinfectant are inaccessible to residents and are in a locked cabinet.

LPA tested the smoke/carbon monoxide and found to be in good working condition. All designated emergency exits and passage ways are clear from obstructions.

1 staff (S1) and ADM were interviewed

Deficiencies were cited per California Code of Regulations, Title 22 during today's visit, See LIC809-D. This report was reviewed with administrator Joyceline Bul-lalayao. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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 02/02/2024 11:03 AM - It Cannot Be Edited


Created By: Maria Partoza On 02/02/2024 at 10:36 AM
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: MCLAUGHLIN MANOR
FACILITY NUMBER: 435201271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 measured bathroom sink water temperature, located across from staff room 2 & 3, and measured at 131 degrees F. LPA measured facility kitchen sink water temperature at 142 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated she will keep a log of the facility water temperature for a week to ensure it stays with in range of 105 -120 degrees F. ADM stated she will send documentation the water is being recorded, to LPA by POC date.
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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/02/2024 11:03 AM - It Cannot Be Edited


Created By: Maria Partoza On 02/02/2024 at 10:37 AM
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: MCLAUGHLIN MANOR
FACILITY NUMBER: 435201271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

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. LPA's observed a broken light switch plate in the hallway bathroom across from resident bedroom #2. LPA observed damaged blinds in resident bedroom #1. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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ADM stated she will send plan of action on how she will address the blinds and broken light switch plate. ADM stated she will send the plan by POC date.
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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
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