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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201454
Report Date: 11/16/2023
Date Signed: 11/25/2023 05:18:48 PM

Document Has Been Signed on 11/25/2023 05:18 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:CARRANZA 2 A.R.F.FACILITY NUMBER:
435201454
ADMINISTRATOR:HELEN CARRANZAFACILITY TYPE:
735
ADDRESS:4339 MOORPARK AVE.TELEPHONE:
(408) 873-7390
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 12CENSUS: 6DATE:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ernie ManaoisTIME COMPLETED:
02:39 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Ernie Manaois.

LPA reviewed 5 resident files and 3 staff files.

LPA toured the facility inside out with HM. License, Administrator Certificate and personal right poster were observed in the office, HM stated the facility will post them at the main entrance. Family room, dinning room, kitchen, office, 4 resident single rooms, 3 resident shared rooms, and 3 restrooms were inspected. The screens of 3 resident bedrooms were observed not in a good repair. There was no night light at the facility hallway. Room temperature was at 72 degree F, and hot water temperature was at 106 degree F. The temperature of the refrigerator was measured at 40 degree F, and the temperature of the freezer was measured at 0 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Knives closet, medication closet, and cleaning product closet were observed locked. The facility is equipped with smoke and carbon monoxide detectors. HM tested the smoker detectors, and they were working fine. Fire extinguisher was serviced on 7/12/2023.

LPA inspected the facility records, it shows the facility had emergency and fire drill on 10/30/2023.

Front yard and backyard were inspected. There was no obstruction to block the walkways.

Citations were noted today. See LIC9099-D. Exit interview was conducted with HM. A copy of this report was provided to HM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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 11/25/2023 05:18 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 11/16/2023 at 01:24 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: CARRANZA 2 A.R.F.
FACILITY NUMBER: 435201454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023

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 in that the screens of 3 resident bedrooms were observed not in good repair, which poses/posed a potential health, safety to persons in care.
POC Due Date: 11/23/2023
Plan of Correction
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Licensee to submit a plan of correction to fix the screens of the 3 resident bedrooms by the POC due date.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 in that no nightlight was observed in the facility hallway which poses/posed a potential, safety risk to persons in care.
POC Due Date: 11/23/2023
Plan of Correction
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Licensee to submit a plan of correction to install nightlights at the hallway by the POC due date.
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: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
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