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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201958
Report Date: 02/20/2025
Date Signed: 02/20/2025 02:18:17 PM

Document Has Been Signed on 02/20/2025 02:18 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:CATHELEEN RCH-I & II DBA:CATHELEEN RCH IIFACILITY NUMBER:
435201958
ADMINISTRATOR/
DIRECTOR:		JULIUS ERVIN JAVIERFACILITY TYPE:
735
ADDRESS:2513 SHILSHONE CIRCLETELEPHONE:
(408) 294-1296
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
02/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Caregiver, Petronio (Ronnie) LiberaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit to follow up on the visit conducted on 1/30/2025. LPA Rai met with Caregiver, Petronio (Ronnie) Libera. LPA Rai spoke with Administrator (ADM) Julius Javier over the phone and stated the purpose of the visit.

The purpose of the visit is to hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical as a staff in the facility. The letter was sealed and handed to the Caregiver, Petronio (Ronnie) Libera.

On 1/30/2025, the Department received an Incident Report stating on 1/29/2025 regarding alleged physical abuse by staff (S1) towards resident (R1). Staff (S2) observed the incident and stated S1 kicked R1 while R1 was crouching down on the floor in the room. S2 stepped in and stopped S1 from kicking R1 again.
Per Administrator (ADM) Julius Javier, S1 employment was terminated immediately after the incident occurred.

During today's visit, the Department issued deficiency under 80072(a)(3) Personal Rights due to S1's physical abuse towards R1. This is a serious matter and the Licensee is culpable of the actions of the employee at the facility.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC 809-D.
Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator (ADM) Julius Javier over the phone and a copy of the report was provided to Caregiver, Petronio (Ronnie) Libera. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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Document Has Been Signed on 02/20/2025 02:18 PM - It Cannot Be Edited


Created By: Simranjit Rai On 02/20/2025 at 09:39 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: CATHELEEN RCH-I & II DBA:CATHELEEN RCH II
FACILITY NUMBER: 435201958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2025
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights (a)(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature,...
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure residents are free of physical abuse by POC due date. Licensee/Administrator agreed and understood.
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Based on interview and record review, R1 was not free of infliction of pain wherein R1 was kicked by S1 while R1 was croutching down on the bedroom floor which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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