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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201710
Report Date: 08/22/2025
Date Signed: 08/22/2025 12:56:50 PM

Document Has Been Signed on 08/22/2025 12:56 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:KERN A.R.F.FACILITY NUMBER:
435201710
ADMINISTRATOR/
DIRECTOR:		SASHI KUMARFACILITY TYPE:
735
ADDRESS:2785 KERN AVE.TELEPHONE:
(408) 281-7057
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 4DATE:
08/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Administrative Assistant Ernie ManoiasTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrative Assistant (AA) Ernie Manoias. During the visit, LPA observed 4 residents and 1 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with 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. 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 75 degrees F, and hot water temperature was measured at 112 degrees F in resident bathroom.

Fire extinguisher was serviced in July 2025. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by AA, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on July 30, 2025.

LPA reviewed facility records for 3 staff and 3 residents. LPA requested to review R1-R4's Appraisal Needs & service plan at 11:09am. Staff S1 stated he/she has not updated their care plans.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: KERN A.R.F.
FACILITY NUMBER: 435201710
VISIT DATE: 08/22/2025
NARRATIVE
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LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 1 resident.

While touring the backyard, LPA noted the ramp adjacent to bedroom 3 had wooden boards that would sink when stepped on. LPA noted that there was also a boards that were not fully nailed down, with the head of a nails sticking out. This creates an uneven walking surface on the ramp.

While touring the hallway bathroom, located between the staff bedroom and bedroom #3, LPA noted there was smudge and stains on the glass mirror. LPA also noted the cover of the air extractor had a layer of dust. LPA also noted the shower's floor had stains and hard water marks.

LPA provided AA annual file review letter requesting documentation to update the facility file. AA stated he will submit the document by 08/25/2025.

Deficiencies cited during today's visit. A technical violation was also given. This report was reviewed with Administrative Assistant Ernie Manoias and a copy of the signed report was provided. Appeal rights were provided.

Page 2 Out of 2. END OF REPORT.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2025 12:56 PM - It Cannot Be Edited


Created By: Manuel Monter On 08/22/2025 at 12:32 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: KERN A.R.F.
FACILITY NUMBER: 435201710

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025

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. Facility ramp adjacent to bedroom 3 had wooden boards that would sink when stepped on and a board that was not fully nailed down, with the head of a nail sticking out. LPA noted dust in the walls of the facility hallway. LPA noted stains on the bathroom mirror and the air extractor had a layer of dust. LPA also noted the shower's floor had stains and hard water marks. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee stated she will submit a written plan of action on how she will address the following: Ramp in the backyard, dust in the hallway, the stains on the bathroom mirror & Shower floor, dust in the bathroom air extractor. Licensee stated her plan of action will ensure the facility is clean, safe, sanitary and in good repair at all times
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Based on a review, R1-R4's Needs and Services plans are not current. S1 stated he/she has not updated R1-R4's care plan. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee stated she will send a letter of understanding regarding the regulation, and the importance of updating a residents Needs and Services plan as often as necessary to assure its accuracy, but at least annually. Licensee stated she will also send LPA a copy of R1-R4's updated Needs and Services Plan.
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 Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
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