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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202041
Report Date:
09/19/2023
Date Signed:
09/19/2023 04:46:11 PM
Document Has Been Signed on
09/19/2023 04:46 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:
LSA - SALERNO HOME
FACILITY NUMBER:
435202041
ADMINISTRATOR:
TANCINCO, ARMIE
FACILITY TYPE:
734
ADDRESS:
1173 SALERNO DR
TELEPHONE:
(408) 429-8274
CITY:
CAMPBELL
STATE:
CA
ZIP CODE:
95008
CAPACITY:
5
CENSUS:
5
DATE:
09/19/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
04:00 PM
MET WITH:
Emilia Tiongson
TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with
Emilia Tiongson
.
The purpose of the visit was to address the Semi-Annual Review Reports cross-reported to the Department from California Department of Developmental Services. One report was conducted on 03/24/2023 and the other on 08/24/2023. The reports included two deficiencies. The first deficiency was for a resident's health assessment not including all of the resident's health conditions. The second deficiency was for a resident not being seen by a Primary Care Physician every 60 days.
LPA Marrufo requests that the facility administrator submit a plan of action explaining how the facility will address the two deficiencies cited by the Department of Developmental Services. LPA Marrufo requests that the administrator submit the plan within 5 business days.
No deficiencies were cited at this time as per California Code of Regulations Title 22.
This report was reviewed with Emilia Tiongson and a copy of the report was provided.
SUPERVISORS NAME
:
Sarah Yip
LICENSING EVALUATOR NAME
:
David Marrufo
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/19/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/19/2023
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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