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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201922
Report Date: 12/21/2024
Date Signed: 12/21/2024 12:29:05 PM

Document Has Been Signed on 12/21/2024 12:29 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:SYLVAN HOMEFACILITY NUMBER:
435201922
ADMINISTRATOR/
DIRECTOR:		MENDINUETO, VERONICAFACILITY TYPE:
735
ADDRESS:3134 SYLVAN DRIVETELEPHONE:
(408) 223-1427
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
12/21/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Administrator Veronica MendinuetoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst LPA Marcela Yanez met with Administrator Veronica Mendinueto During the visit, LPA observed 5 residents and 4 staff. LPA explained the purpose of the visit. the facility is approved for Age Range 18 through 59, all may be non ambulatory.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms that had grab bars and non skid mats and 3 residents bedrooms.

While touring the facility LPA observed residents doing activity.

During inspection LPA observed 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 117.8 degrees F in both resident bathrooms and in kitchen sink was 115.1 F degrees.

The staff bedroom was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways and ramp. In bedroom #2 the ramp leading to the backyard has rotten wood broken and loose floor boards this is a tripping hazard and is an immediate risk for residents in care since it is an emergency exit. (pictures taken)

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2024
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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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: SYLVAN HOME
FACILITY NUMBER: 435201922
VISIT DATE: 12/21/2024
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Fire extinguisher was serviced in 11/09/2023 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 10/25/24

LPA reviewed facility records for 4 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA interviewed 3 staff and 1 resident

Deficiencies cited during today's visit (see 809-D) This report was reviewed with Veronica Mendinueto and a copy of the signed report was provided and a copy of Appeals Rights were provided.

End of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2024 12:29 PM - It Cannot Be Edited


Created By: Marcela Yanez On 12/21/2024 at 11:33 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: SYLVAN HOME
FACILITY NUMBER: 435201922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 bservation and interview, the licensee did not comply with the section cited above the facility ramp exiting bedroom #2 with rotten wood, broken pieces and loose floor board its a tripping hazard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2024
Plan of Correction
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ADM stated she will provide a letter of understanding by the poc date and stated she will repair the deck. ADM stated she spoke with contractor and scheduled an appointment for repair.
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:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2024


LIC809 (FAS) - (06/04)
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