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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202041
Report Date: 02/19/2025
Date Signed: 02/19/2025 04:27:10 PM

Document Has Been Signed on 02/19/2025 04:27 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 HOMEFACILITY NUMBER:
435202041
ADMINISTRATOR/
DIRECTOR:		TANCINCO, ARMIEFACILITY TYPE:
734
ADDRESS:1173 SALERNO DRTELEPHONE:
(408) 429-8274
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 5CENSUS: 4DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:39 PM
MET WITH:Staff, Seble TamiratTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced at 1:39PM to conduct the facility's Required-1 year annual inspection. ADM Armie Tancinco was not present during today's inspection. ADM authorized Staff Seble Tamirat to complete inspection with LPA Tarin. LPA toured the interior and exterior of the facility with Staff to include the kitchen, office, client rooms, dining room, bathrooms, and the back and front of the facility. Facility thermostat temperature display was observed at 72 degrees F. All exit and passageways were free and clear of obstruction.

LPAs toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days.

LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. LPAs measured kitchen sink hot water temperature at 120 degrees F.

The facility was equipped with smoke and carbon monoxide detectors. The smoke detectors were last inspected on 4/8/2024. Fire extinguishers were last serviced on 6/26/2024. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last emergency drill was on 2/10/2025. Drills are being conducted quarterly.

LPA toured 5 client bedrooms. 5 out of 5 client bedrooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 1 client bathroom and 1 staff bathroom. 2 out of 2 bathrooms had hand soap, paper towel, functioning lights, and covered trash bins. LPA measured water temperature in 2 out of 2 bathrooms, measuring 117 degrees F.

See LIC809C
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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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: LSA - SALERNO HOME
FACILITY NUMBER: 435202041
VISIT DATE: 02/19/2025
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LPA reviewed 4 client records. 4 out of 4 clients records were found to be complete. Client records included emergency contact information, physician’s report, needs and service plans, and personal rights.

LPA reviewed 4 client's Centrally Stored Medication and Destruction Records (CSMDR’s). 4 out of 4 CSMDR’s were observed to be complete with all medication documented.

LPA was unable to review staff records during inspection. LPA spoke with ADM regarding the staff records. ADM stated the staff records were in a locked cabinet, and staff do not have a key to the cabinet. ADM states they will email LPA copies of staff records by 2/20/2025. A Technical Violation was issued. LPA advised ADM that staff records shall be available to the Licensing agency.

No deficiencies were cited during today's visit per California Code of Regulations Title 22. A Technical Violation was issued. See LIC9102 for more information. An exit interview was conducted with Staff Seble Tamirat, and a signed copy of this report was provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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