435201758-8-20-2025-26-AS-CKAI-DKQPJ6-20250820112102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201758
Report Date: 08/20/2025
Date Signed: 08/20/2025 11:21:11 AM

Document Has Been Signed on 08/20/2025 11:21 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:	NEO NICHOLAS MANOR		FACILITY NUMBER:	435201758
ADMINISTRATOR/ DIRECTOR:	CHRISTIA-MARIE MENDOZA		FACILITY TYPE:	735
ADDRESS:	14961 RIDGETOP DRIVE		TELEPHONE:	(408) 708-7928
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY: 6		CENSUS: 6	DATE:	08/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Christia-Marie Mendoza		TIME VISIT/ INSPECTION COMPLETED:	11:25 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) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Administrator (ADM), Christa-Marie Mendoza and Lead Staff, Maria Grieve. ADM left in the middle of the visit as ADM had to attend a scheduled meeting. LPA toured the facility with staff to include 3 resident bedrooms, 2 bathrooms, 2 staff bedrooms, garage, backyard, storage unit, and exterior. All fire exit routes were free and clear of obstruction, There were no residents on site during visit as all the residents were attending day program. 3 staff members present are fingerprint cleared and associated to the facility. Facility temperature maintained at 72 degrees F. Fire extinguisher in the kitchen last serviced on 03/12/2025. Smoke detector observed operable. During visit, the facility did not have a carbon monoxide detector installed as the staff thought the smoke alarm was dual with carbon monoxide. The smoke detectors did not indicate it also included carbon monoxide. During visit, staff found the carbon monoxide detectors in the cabinets and installed them right away. Carbon monoxide detector observed operable. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 34 degrees F. Freezer temperature maintained at 0 degrees F. Sharp objects, chemicals and disinfectants observed locked. Resident bedrooms equipped with beds, linens, closet space/dresser, and adequate lighting. All window screens observed in good repair. See LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

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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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: NEO NICHOLAS MANOR	FACILITY NUMBER: 435201758
	VISIT DATE: 08/20/2025

NARRATIVE

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Bathroom hot water temperature maintained at 132.6 degrees F. A type A deficiency was cited today per Section 80088(e)(1) wherein the hot water temperature exceeded 120 degrees F.

LPA observed the toilet seat in bathroom #2 was removed. Staff stated that on 08/19/2025, a resident broke off the toilet seat. Staff and ADM stated a plan to replace the toilet seat today. A technical violation was provided per Section 80088(e)(3) wherein the toilet did not have a toilet seat which may be a safety concern when in use. The shower is equipped with grab bars and non-slip floors.

LPA reviewed 3 resident files were complete and up-to-date. 3 resident's centrally stored medications and centrally stored medication records were reviewed and all medications were accounted for. 3 resident's P&I money was counted with the staff and all money was accounted for, no issues noted.

During the record review, LPA observed 1 out of 3 residents had a restricted health condition care plan. ADM was advised that the restricted health condition may require an exception request from the Department. ADM and LPA will collaborate regarding documents required.

LPA reviewed 3 staff files were complete. 3 staff has an active first aid certification, health screening, TB result, fingerprint clearance, and annual training records.

Emergency drills are conducted quarterly, the last drill was completed on 07/05/2025. Facility has an emergency disaster plan. Facility had 4 first aid kits located in the kitchen.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note provided. This report was reviewed with lead staff, Maria Grieve as ADM was not available during the exit interview and a copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/20/2025 11:21 AM - It Cannot Be Edited

Created By: Christine Kabariti On 08/20/2025 at 11:01 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: NEO NICHOLAS MANOR	FACILITY NUMBER: 435201758
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2025

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 in wherein the hot water temperature was maintained at 132.6 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2025
	Plan of Correction
1 2 3 4	Lead staff states they will adjust the temperature of the water today. Lead staff states they will take a picture of the hot water temperature and submit the picture to LPA Kabariti via email by POC due date of 08/21/2025.

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.

	Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:

	Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC809 (FAS) - (06/04)

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