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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201311
Report Date: 12/20/2021
Date Signed: 12/20/2021 12:44:29 PM

Document Has Been Signed on 12/20/2021 12:44 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:ROSSMORE A.R.F. HOMEFACILITY NUMBER:
435201311
ADMINISTRATOR:HELEN V. CARRANZAFACILITY TYPE:
735
ADDRESS:2955 ROSSMORE LANETELEPHONE:
(408) 531-9487
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
12/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Ernie ManaoisTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Ernie Manaois. The purpose of the visit was to check on the welfare of the residents after an Suspected Adult Abuse form was submitted to the Department stating that resident R1 had entered into R2's bedroom, stole R2's radio, and pushed R2. According to the Suspected Adult Abuse report, R2 contacted the police and police arrived at the home. Police did not observe any injuries on R2.

LPA Marrufo toured the facility. During visit, staff S1 stated that resident R2 is not present at the facility. LPA Marrufo observed that R2's bedroom was locked during the visit. Staff S1 unlocked the bedroom at LPA's request. LPA Marrufo attempted an interview with resident R1, but R1 would not respond to LPA Marrufo's interview questions.

LPA Marrufo interviewed residents R3-R5, who stated the facility provides them with enough supervision and enough meals each day.

Staff Ernie Manaois stated that he purchased new radios for R1 and R2 to keep in their rooms. He stated no incident report was filed with licensing in regards to the visit.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Ernie Manaois and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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 12/20/2021 12:44 PM - It Cannot Be Edited


Created By: David Marrufo On 12/20/2021 at 12:26 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: ROSSMORE A.R.F. HOME
FACILITY NUMBER: 435201311

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2021
Section Cited
CCR
80061(b)(E)

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Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day
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Licensee agrees to submit an incident report for the incident involving R2 alleging that R1 shoved R2 twice and entered R2's room and also agrees to conduct staff training on reporting requirements
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during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by: Licensee did not file an incident report when resident R2 called the police on 11/16/2021 stating R1 had entered R2's room and shoved R2 twice, which poses a potential safety risk to residents in care.
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and submit training roster with training topics to CCL by POC date.

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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:Jackie Jin
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2021


LIC809 (FAS) - (06/04)
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