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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201311
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:10:44 PM

Document Has Been Signed on 07/24/2024 03:10 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:ROSSMORE A.R.F. HOMEFACILITY NUMBER:
435201311
ADMINISTRATOR/
DIRECTOR:		HELEN V. CARRANZAFACILITY TYPE:
735
ADDRESS:2955 ROSSMORE LANETELEPHONE:
(408) 531-9487
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 4DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Ernie ManaoisTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1 year annual inspection. LPA met with Administrator, Ernie Manaois.

During visit, LPA toured the facility with staff to include 4 out of 4 resident bedrooms, bathrooms, 1 staff room, living room, office, kitchen, laundry room, and backyard. The shed in the backyard was observed to contain storage items. Facility observed to be well maintained. LPA observed a camera in the common areas. Backyard contained a shaded seating area. All fire exit routes were free and clear of obstruction. There was 1 staff to 3 residents present during visit.

Facility temperature maintained between 86 - 89 degrees Fahrenheit, with the outside temperature at 95 degrees Fahrenheit. Facility has an AC unit that was turned on during visit. Every resident bedrooms and living rooms contains a fan. Fire extinguisher last serviced on 07/12/2023. Administrator states they have a schedule day to re-service the fire extinguishers. A carbon monoxide detector observed present in the kitchen. Kitchen observed with at least 2 days worth of perishable and 7 days worth of non-perishable foods. LPA observed fruits and vegetables inside the kitchen refrigerator. Facility has 2 refrigerators located in the kitchen and dining room area. Refrigerator temperature in the kitchen is maintained at 56 degrees Fahrenheit. Refrigerator temperature in the dining room maintained at 32 degrees Fahrenheit. Staff moved items from the kitchen refrigerator to the dining room refrigerator during visit. Freezer temperatures maintained at 0 degrees Fahrenheit. Sharp objects, chemicals, disinfectants, and medications observed locked.

Resident bedrooms contains a bed, linens, dresser, and lighting. 4 out of 4 resident bedrooms windows observed with screens. Bathroom hot water temperature maintained at 114 degrees Fahrenheit. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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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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: ROSSMORE A.R.F. HOME
FACILITY NUMBER: 435201311
VISIT DATE: 07/24/2024
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LPA reviewed 3 resident files. 3 out of 3 resident files were complete to include a signed admission agreement, updated appraisal/needs and services plan, physician's report, TB result, weight record, identification and emergency contact information, safeguard of personal properties and valuables, consent and personal rights form. 3 out of 3 residents centrally stored medications and centrally stored medication records observed maintained. 2 residents were interviewed.

LPA reviewed 2 staff files. 2 out of 2 staff files were maintained to include fingerprint clearance, LIC501, LIC503, TB result, and 1st aid certification.

Facility has an infection control plan. Infection control plan training is completed.

Facility has an emergency disaster plan. LPA advised to utilize the new LIC610D. Administrator stated understanding. LPA observed the first aid kit and emergency lighting. Emergency drills were reviewed and observed to be conducted quarterly.

The following documents were requested via email since the facility does not have a copy machine: LIC308, Administrator Certificates, LIC500, LIC400, Surety Bond, and LIC610D.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Administrator, Ernie Manaois and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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