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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201311
Report Date: 02/10/2024
Date Signed: 02/10/2024 11:55:08 AM

Document Has Been Signed on 02/10/2024 11:55 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: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:
02/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrative Assistant Ernie Manaois.
TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrative Assistant Ernie Manaois.

While investigating the complaint dated February 4, 2022, LPA reviewed R1’s Appraisal Needs and Services Plan (ANS), dated December 15, 2021. R1’s ANS’s Socialization/Emotional sections are empty. R1's ANS form is also not signed. Based on a review of R1’s Physician’s Report, dated December 8, 2020, R1 has a mental disorder. R1’s physician report also states R1 does exhibit inappropriate behavior.

LPA reviewed R2’s Needs and Services Plan, dated October 24, 2021 R2’s ANS’s socialization and emotional section is empty. Based on a review of R2’s Physician’s Report, dated February 23, 2021, R2 has a mental disorder. The form also states R2 has aggressive behavior and is depressed.

Based on interviews conducted Staff S1 confirmed that the incident where R1 shoved R2 occurred in January 2022. S1 stated he/she witnessed R1 shove R2 and he/she intervened. S1 stated he/she then separated the residents. LPA requested the incident report, AA stated the facility did not send an incident report for this interaction with R1 and R2.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrative Assistant Ernie Manaois and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2024
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 2
Document Has Been Signed on 02/10/2024 11:55 AM - It Cannot Be Edited


Created By: Manuel Monter On 02/10/2024 at 10:42 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: ROSSMORE A.R.F. HOME
FACILITY NUMBER: 435201311

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2024
Section Cited
CCR
85068.3(a)

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85068.3 Modifications to Needs and Services Plan (a) The written Needs and Services Plan ...shall be updated as frequently as necessary to ensure its accuracy, and to document ... client's physical, mental and/or social functioning. This Requirement was not met as evidenced by
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ADM stated he/she will send letter of understanding regarding the regulation, and ensuring that residents Appraisal needs and Services plan is updated and accurate to document residents physical, mental, emotional, social, and functioning needs are being met.
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Based on record review of R1 and R2's Appraisal Needs and Services Plan, both plans have sections blank with "N/A". This poses/posed a potential health, safety or personal rights risk to persons in care.
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ADM stated he/she will send plan of action by POC date, 2/17/2024.
Type B
02/17/2024
Section Cited
CCR80061(b)(1)(E)

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80061 Reporting Requirements (b)(1)(E) Any unusual incident ... which threatens the physical or emotional health or safety of any client...constitute an unusual incident...
This requirement was not met as evidenced by;
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ADM stated he/she will send letter of understanding regarding the regulation and the importance of sending incident reports. ADM stated he/she will send the letter by POC date, 2/17/2024
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Based on record review and interviews; AA stated the facility did not send an incident report regarding the incident where R1 pushed R2 in the hallway. This poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2024


LIC809 (FAS) - (06/04)
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