<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201757
Report Date: 06/14/2024
Date Signed: 06/14/2024 10:20:03 AM

Document Has Been Signed on 06/14/2024 10:20 AM - 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 (2) HOMEFACILITY NUMBER:
435201757
ADMINISTRATOR/
DIRECTOR:		BASA, ELEANORFACILITY TYPE:
735
ADDRESS:893 RENTON COURTTELEPHONE:
(408) 224-6224
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 2DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Staff S1, Eleanor BasaTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff S1, Sharon Basa. During the visit, LPA observed 0 residents and 2 staff.

LPA toured the facility inside out with 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. There was no obstruction to block the walkways.

While touring bathroom #1 LPA observed the shower handle to contain a layer of white and black marks. LPA also observed the bottom portion of the shower head had an orange stain. (Photographs were taken.) LPA also measured the hot water temperature in bathroom #1, which measure at 138 degrees F. (Photographs were taken.)

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.

Fire extinguisher was serviced in February 6, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on April 15, 2024.

LPA reviewed facility records for 3 staff and 2 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 0 residents. Residents were attending day program during LPA's Visit.

Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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 4
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 (2) HOME
FACILITY NUMBER: 435201757
VISIT DATE: 06/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA requested a copy of the following documents to be sent to the Department by June 21, 2024.
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. LIC200, please update (i.e., new phone numbers etc), if necessary.
6. Qualifications of Administrator (Certificate)
7. Please review your facility program for updates (incorporating new laws and/or regulations)
8. Please submit copy of surety bond

Deficiencies are being cited during today's visit, see LIC809-D. This report was reviewed with staff S1, Sharon Basa and a copy of the signed report was provided. Appeal rights were provided.

END OF REPORT

Page 2 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/14/2024 10:20 AM - It Cannot Be Edited


Created By: Manuel Monter On 06/14/2024 at 09:52 AM
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: ELEANOR'S GLACIER (2) HOME
FACILITY NUMBER: 435201757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA measured the hot water temperature in bathroom #1, which measured at 138 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2024
Plan of Correction
1
2
3
4
ADM agrees to submit a Plan of Correction by POC date to ensure that water temperatures in the sinks of all resident bathrooms are between 105 F to 120 F. ADM shall submit video evidence to CCL once bathroom sink temperatures are corrected. ADM stated she will also send a letter of understanding regarding the regulation. ADM stated she will send the Plan of Corrections by POC date, June 15, 2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/14/2024 10:20 AM - It Cannot Be Edited


Created By: Manuel Monter On 06/14/2024 at 09:52 AM
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: ELEANOR'S GLACIER (2) HOME
FACILITY NUMBER: 435201757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. While touring bathroom #1 LPA observed the shower handle to contain a layer of white and black marks. LPA also observed the bottom portion of the shower head had an orange stain. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
1
2
3
4
ADM stated she will send photo documentation showing the facility bathroom #1 is clean, sanitary and in good repair. ADM stated she will send photo documentation by POC date, June 21, 2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4