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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201523
Report Date: 01/25/2024
Date Signed: 01/25/2024 05:40:26 PM

Document Has Been Signed on 01/25/2024 05:40 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:ELEANOR'S GLACIER 1 HOMEFACILITY NUMBER:
435201523
ADMINISTRATOR:ELEANOR BASAFACILITY TYPE:
735
ADDRESS:5863 TREETOP COURTTELEPHONE:
(408) 629-9183
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Sharon BasaTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual inspection to the facility. LPA met with lead staff Sharon Basa. Administrator (ADM) Eleanor Basa was not available at the time of visit. LPA called ADM and ADM stated that he/she gives authorization and consent to SB to receive and sign on her behalf during her absence.

Current census 5 residents. 5 Out of 5 are non-ambulatory.

During visit, LPA toured the facility to include the living room, dining room, kitchen, bedrooms, bathroom, garage, and backyard. Staff room was inspected, 2 bathroom was inspected. LPA observed all areas are kept clean and sanitary condition. The bathroom and kitchen hot water temperature was measured at 119.8F to 120F. The temperature in the facility was at 68-75F.

Perishable and non-perishable food supply are within required regulation. Toiletries such toilet paper, paper towels, toothpaste are inspected and found to be in ample supply. Toxic materials such as laundry detergent, disinfectant are inaccessible to residents are stored in a locked cabinet.

LPA observe expired non-perishable and perishable food items. Designated emergency exits (sliding doors) are not maintained for easy access. A technical advisory was assessed for grounds maintenance.

Annual required inspection to be continued at a later date.

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Continued on Page 2 LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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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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: ELEANOR'S GLACIER 1 HOME
FACILITY NUMBER: 435201523
VISIT DATE: 01/25/2024
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continued from page 1 LIC 809

The following documents were requested, updated LIC 308, LIC 309, Administrative Organization LIC400, LIC 500, affidavit regarding client/resident cash resources, LIC 610D, Emergency Disaster.

Deficiencies were observed and not cited during today's visit. The following deficiency and advisory will be cited a later date due to time constraint.

1. 80075(k)(1)-Health Related Services- 5 Out of 5 residents' medications were accessible or not locked.
2. LIC was made advised of the sliding doors' condition and ability to open with ease. As a designated exit in the staff bedroom (based on physical floor plan) and living area, sliding doors should work properly for ease of access. ADM stated he/she will do necessary maintenance of the doors. The backyard pavement were found to be uneven and loose requiring maintenance and fire extinguisher was last inspected on 4/29/2022. ADM stated the inspection is scheduled to be inspected on 2/6/2024.

This report was reviewed with administrator (ADM) Eleanore Basa.

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end of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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