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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201319
Report Date: 05/08/2024
Date Signed: 05/08/2024 05:05:25 PM

Document Has Been Signed on 05/08/2024 05:05 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:CAPRI HOMEFACILITY NUMBER:
435201319
ADMINISTRATOR/
DIRECTOR:		GANIYU AJANIFACILITY TYPE:
735
ADDRESS:1849 ST. ANDREWS PLACETELEPHONE:
(408) 254-9452
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 6DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:21 PM
MET WITH:GANIYU AJANITIME VISIT/
INSPECTION COMPLETED:
04:52 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Ganiyu Ajani.

LPA toured the facility inside and out with ADM. License, Administrator Certificate, and personal rights posters were observed in the facility.

6 residents and 7 staff were observed in the facility. LPA reviewed 3 resident file and 3 staff files.

Living room, kitchen, dining room, restrooms, and laundry rooms were inspected. 2 single resident bedrooms, 2 shared resident bedrooms, and offices were inspected. one staff room in the first floor and 3 staff rooms at the second floor were observed. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and chemical closet were observed locked. Room temperature was at 69 degree F, and hot water temperature was at 112 degree F in facility. The temperature of the refrigerator was at 20 degree F, and the temperature of the freezer was at 0 degree F.

Fire extinguisher was serviced on 12/12/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by ADM, and were working fine. First aid box and flash lights were observed in the facility. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated the last time the facility conducted the emergency and fire drill was on 4/28/2024.

Deficiencies were noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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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Document Has Been Signed on 05/08/2024 05:05 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 05/08/2024 at 03:57 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: CAPRI HOME
FACILITY NUMBER: 435201319

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 1 out of 3 resident P&I money was observed did not match the transaction log balance which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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ADM stated to submit the plan of correction by the POC due date to maintain the resident P&I money accurate and up to date.
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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024


LIC809 (FAS) - (06/04)
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