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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201454
Report Date: 11/05/2024
Date Signed: 11/05/2024 05:09:51 PM

Document Has Been Signed on 11/05/2024 05:09 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:CARRANZA 2 A.R.F.FACILITY NUMBER:
435201454
ADMINISTRATOR/
DIRECTOR:		HELEN CARRANZAFACILITY TYPE:
735
ADDRESS:4339 MOORPARK AVE.TELEPHONE:
(408) 873-7390
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 12CENSUS: 6DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:36 AM
MET WITH:Ernie ManaoisTIME VISIT/
INSPECTION COMPLETED:
01:33 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 3 resident files and 3 staff files. LPA observed 5 residents and 1 staff in the facility.

LPA notified HM that the facility has balance to pay. HM stated the facility will pay it today.

LPA toured the facility inside and out with HM. License, Administrator Certificate were observed in the facility. Personal Right posters were not observed in the office. HM posted them at the main entrance before LPA finished the visit. Family room, dinning room, kitchen, office, 4 resident single rooms, 3 resident shared rooms, 1 staff live-in room, and 3 restrooms were inspected. The restrooms were observed without non-skid mats. HM put the non skid mats in the restroom before LPA finished the inspection. There was no night light at the facility hallway. HM installed the night lights immediately. Room temperature was at 70 degree F, and hot water temperature was at 116 degree F. The temperature of the refrigerator was at 35 degree F, and the temperature of the freezer was 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 not locked. HM locked them immediately. 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 7/29/2024.

Continue on LIC809-C. Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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 3
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: CARRANZA 2 A.R.F.
FACILITY NUMBER: 435201454
VISIT DATE: 11/05/2024
NARRATIVE
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LPA observed the first aid box and flash lights in the facility.

LPA inspected the facility records, it shows the facility had emergency drill on 9/30/2024. LPA reviewed with HM for LIC500, the facility does not have sufficient staff to cover 24 x 7 hours.

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

Citations were noted today. See LIC809-D. Exit interview was conducted with HM. A copy of this report was provided to HM.


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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/05/2024 05:09 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 11/05/2024 at 01:13 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: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85065.5(a)(2)
Day Staff-Client Ratio
(2) For all other clients, there shall be a staff-client ratio of no less than one direct care staff to three such clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that LPA observed only 1 staff and 5 residents in the facility, and another staff came in the facility around 1 hour after LPA arrived at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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House manager stated the facility will send a plan of correction by the POC due date to hire more staff to ensure the facility to provide the necessary care and supervision to residents.
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: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
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