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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201549
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:10:50 PM

Document Has Been Signed on 02/15/2024 02:10 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:CORKTREE HOUSEFACILITY NUMBER:
435201549
ADMINISTRATOR:CAYABYAB, PERLAFACILITY TYPE:
735
ADDRESS:2170 CORKTREE LANETELEPHONE:
(408) 499-3708
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 6DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lead Staff Gimenia ManuelTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff Armondo Nodara (S1). During the visit, LPA observed 2 residents and 2 staff. Lead staff, Gimenia Manuel (S2) arrived shortly after.

LPA toured the facility inside out with staff S1 which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected.

While touring the backyard, LPA observed Exit #3, for the living room does not have a screen. The living room windows facing the backyard do not have screens. LPA observed bedroom #3 does not have a screen. S1 pointed out that the screens are not attached and are laying on the side of the fence. (Photographs were taken.) There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 117 degrees F in both resident bathrooms.

Fire extinguisher was serviced in January 16, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on January 2, 2024. Upon review of the facility earthquake/fire drill log, the facility conducted drills on the following dates; March 3, 2023, May 29, 2023, June 3, 2023. The facility did not conduct a drill for the third or fourth quarter of 2023.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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 02/15/2024 02:10 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/15/2024 at 01:47 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: CORKTREE HOUSE
FACILITY NUMBER: 435201549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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. LPA observed Exit #3, for the living room does not have a screen. The living room windows facing the backyard do not have screens. LPA observed bedroom #3 does not have a screen. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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ADM stated she will send written plan of action on how the facility will ensure all window screens are in good repair and installed. ADM stated she will also send photo documentation to LPA showing the screens have been installed, by POC date, 2/22/2024.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. The facility earthquake/fire drill log states the facility conducted drills on the following dates; March 3, 2023, May 29, 2023, June 3, 2023. The facility did not conduct a drill for the third or fourth quarter of 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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ADM stated she will send a written plan of action on how the facility shall conduct a drill at least quarterly for each shift and ensure documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. ADM stated she will send the plan of action, by POC date, 02/22/2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


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: CORKTREE HOUSE
FACILITY NUMBER: 435201549
VISIT DATE: 02/15/2024
NARRATIVE
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LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records. LPA conducted interviews with 2 staff (S1 to S3) and 2 residents (R1-R2). The other residents were in day program during LPA's visit.

Deficiencies are being cited during today's visit. This report was reviewed with Lead Staff Gimenia Manuel and a copy of the signed report was provided. Appeal rights were provided. LPA called Administrator to review the report, but no answer. LPA left voicemail at 1:56pm.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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