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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201319
Report Date: 12/11/2023
Date Signed: 12/11/2023 12:46:00 PM

Document Has Been Signed on 12/11/2023 12:46 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
Lookup Error,
, CA
FACILITY NAME:CAPRI HOMEFACILITY NUMBER:
435201319
ADMINISTRATOR:GANIYU AJANIFACILITY TYPE:
735
ADDRESS:1849 ST. ANDREWS PLACETELEPHONE:
(408) 254-9452
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 6DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ganiyu Ajani, LicenseeTIME COMPLETED:
12:50 PM
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On 12/11/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit, and met with Licensee Ganiyu Ajani. LPA toured facility with Licensee. One client was present upon LPA arrival and left on outing during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature was maintained at 24 degrees F and freezer at-1 degrees F. Medications were observed locked in kitchen shelf. MARs were reviewed. Fire extinguisher was observed with a purchased date of: 11/04/2022. Fire drill last completed: 09/12/23.

All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were properly equipped and operating. Hot water temperature was tested at 106.5 degrees F in bathroom and 120 degrees F in master bathroom. Cleaning supplies and chemicals stored in garage cabinet. Outside of facility toured and observed to be free of debris. Side gate observed self-closing and self-latching.

All clients’ files were reviewed to have all the required documents. Sample of Staff files were also reviewed and observed to have all required documents. Carbon monoxide and smoke detectors were tested and observed to be operational.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22. Division 6.Exit Interview conducted. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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 12/11/2023 12:46 PM - It Cannot Be Edited


Created By: Mai Yang On 12/11/2023 at 12:14 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
,
, CA

FACILITY NAME: CAPRI HOME
FACILITY NUMBER: 435201319

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85064(f)
Administrator Qualifications and Duties (f) When the administrator is … responsible and accountable for, management and administration of the facility in compliance with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA and Licensee observed Fire Extinguishers has a service date of 11/04/2022, which poses an immediate health and safety risk to the clients.
POC Due Date: 12/12/2023
Plan of Correction
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Licensee states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 12/12/2023.
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:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
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