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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201493
Report Date: 01/31/2025
Date Signed: 01/31/2025 03:01:15 PM

Document Has Been Signed on 01/31/2025 03:01 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:A HEAVENLY CARE HOMEFACILITY NUMBER:
435201493
ADMINISTRATOR/
DIRECTOR:		FONTANILLA, DIANAFACILITY TYPE:
740
ADDRESS:259 CHECKERS DRIVETELEPHONE:
(408) 926-3285
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
01/31/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Staff S1 Cleofe LucasTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced visit to open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Staff (S1) Cleofe Lucas. Staff S1 informed LPA that the Administrator was on vacation. LPA contacted the facility's designee (FD) (based on a review of the facility's LIC309). FD stated he/she was preoccupied due to an emergency. FD stated staff S1 could sign on his/her behalf.

While investigating the complaint 26-AS-20250128124742, LPA toured the facility. While touring the backyard, LPA observed 12 pieces of bread, with mold in the backyard, directly across from exit #2, in the dinning room. (Photographs were taken.) LPA spoke with FD via phone call, who stated, the staff put the bread there to feed the birds. Staff S1 disposed of the molded bread during visit.

While touring resident bedroom #3, LPA observed the doorway to the private bath did not have a door. LPA observed it only contained a brown curtain. LPA took photographs of the bathroom, from the inside of bedroom #3. (Photos with light on and off.) Based on observation, the curtains do not obscure the inside of the bathroom, resulting in a violation of a residents personal rights to privacy and dignity when using the restroom.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Staff S1 Cleofe Lucas and a copy of the report and appeal rights were provided.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112
DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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 2
Document Has Been Signed on 01/31/2025 03:01 PM - It Cannot Be Edited

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: A HEAVENLY CARE HOME
FACILITY NUMBER: 435201493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87468.1(a)(1)
87468.1 Personal Rights of Residents in All Facilities (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by;
Deficient Practice Statement
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POC Due Date: 02/01/2025
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure residents who use the private bathroom, in bedroom #3 are accorded privacy and dignity.

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.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112

DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2025

LIC809 (FAS) - (06/04)
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