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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201758
Report Date: 08/15/2024
Date Signed: 08/15/2024 05:05:31 PM

Document Has Been Signed on 08/15/2024 05:05 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NEO NICHOLAS MANORFACILITY NUMBER:
435201758
ADMINISTRATOR/
DIRECTOR:		CHRISTIA-MARIE MENDOZAFACILITY TYPE:
735
ADDRESS:14961 RIDGETOP DRIVETELEPHONE:
(408) 708-7928
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 6DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Christia Mendoza VasquezTIME VISIT/
INSPECTION COMPLETED:
12:33 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Christia Mendoza Vasquez . LPA observed 3 staff in the facility, and all the residents went to day program.

LPA reviewed 3 resident files and 3 staff files. LPA toured the facility inside out with ADM. License, ADM certificate and Personal rights posters were observed in the facility. Living room, kitchen, dinning room and two restrooms were inspected. 3 resident bedrooms, and laundry room were inspected. Two staff live-in rooms was observed in facility. One storage room was observed in the garage. One staff live-in room was observed in the garage. ADM change the room back to storage room immediately. The temperature of the freezer in the kitchen was observed at 30 degree F. The refrigerator in the kitchen was observed not cool enough. ADM stated the facility has a backup refrigerator in garage. ADM stated the facility is planing to replace the refrigerator in the kitchen with a new one. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 77 degree F, and hot water temperature was at 108 degree F in facility. First Aid box, Flash lights and night lights were observed in the facility. The last time the facility conducted the emergency drill is 4/7/2024.

Fire extinguisher was serviced on 03/19/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. One storage room was observed in the back yard.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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 3
Document Has Been Signed on 08/15/2024 05:05 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 08/15/2024 at 12:28 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: NEO NICHOLAS MANOR
FACILITY NUMBER: 435201758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(2)
Food Service
(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (-17.7 degrees C).

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 in that the temperature of the freezer of the refrigerator in the kitchen was observed at 30 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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ADM stated to send a plan of correction by the POC due date to replace the refrigerator with a new one.
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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/15/2024 05:05 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 08/15/2024 at 12:28 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: NEO NICHOLAS MANOR
FACILITY NUMBER: 435201758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

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 in that the window screen of one of the restroom was observed missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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ADM stated to send a plan of correction by the POC due date to install a new window screen for the restroom.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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