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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201311
Report Date: 01/13/2024
Date Signed: 01/13/2024 12:55:44 PM

Document Has Been Signed on 01/13/2024 12:55 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:HELEN V. CARRANZAFACILITY TYPE:
735
ADDRESS:2955 ROSSMORE LANETELEPHONE:
(408) 531-9487
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
01/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrative Assistant Ernie ManaoisTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrative Assistant (AA) Ernie Manaois. During visit, LPA observed 4 residents and 1 staff.

LPA toured the facility inside out with staff S1 which included; the Living room, kitchen, dining room, 2 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 117 degrees F in both resident bathrooms.

While touring the home LPA observed multiple windows, without screens. LPA observed resident bedrooms 4, Bedroom #3, & the dinning room window without window screens. While touring the home LPA observed the shower walls in the bathroom between Bedroom #4 and Bedroom #3 had soap scum stains. LPA observed ice build up in the facility fridge, in front of the oven. LPA also observed duct tape holding up the shelves of the fridge as well. LPA observed the fan in the dinning room had clumps of dust on the fan. LPA observed several empty cardboard trays in the backyard. LPA observed an empty plastic bad and a empty cloths basket on the ground. LPA observed two cobwebs in bedroom #4; one in the corner of the room, directly perpendicular to the door. LPA also observed a cobweb above the closet. The door to bedroom #4 also had an indent the size of a door knob. LPA observed one of the light panels above the kitchen was not working, the light directly above the fridge and oven area. (LPA took photographs of all LPA's observations.)

Fire extinguisher was serviced in June 12, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by AA, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on January 5, 2024. Page 1 out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2024
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 4
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: 01/13/2024
NARRATIVE
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LPA reviewed facility records for 2 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff (S1 to S2) and 3 residents (R1-R3). AA stated the care giver forgot to record the residents weights. AA stated starting January 2024, the facility will begin recording the residents weights.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrative Assistant Ernie Manaois and a copy of the signed report & appeal rights were provided.

Page 2 out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/13/2024 12:55 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/13/2024 at 12:25 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: 01/13/2024

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 also observed duct tape holding up the shelves of the fridge as well. LPA observed the fan in the dinning room had clumps of dust on the fan. LPA observed one of the light panels above the kitchen was not working, the light directly above the fridge and oven area. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2024
Plan of Correction
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4
ADM stated he will send plan of action on how the facility will ensure it remains clean, safe, sanitary and in good repair at all times. ADM stated he will send plan of action by POC date, 1/20/2024.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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. Based on LPA's observations, resident Bedroom 4, Bedroom #3, & the dinning room window did not have window screens. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will maintain all window screen in good repair and free of insects and other debris. ADM stated he/she will send plan of action to LPA by POC date, 1/20/2024.
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: 01/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/13/2024 12:55 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/13/2024 at 12:28 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: 01/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85075.4(c)
The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review and interview, the licensee did not comply with the section cited above. AA stated, the care giver forgot to record the residents weights for 2023. AA stated starting January 2024, the facility will begin recording the residents weights. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2024
Plan of Correction
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ADM stated he/she will send plan of action on how the facility will observe changes to residents wights. ADM stated he/she will send to LPA by POC date, 1/20/2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2024


LIC809 (FAS) - (06/04)
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