<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202052
Report Date: 01/09/2025
Date Signed: 01/09/2025 01:02:02 PM

Document Has Been Signed on 01/09/2025 01:02 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:MARILAG'S CARE HOMEFACILITY NUMBER:
435202052
ADMINISTRATOR/
DIRECTOR:		WENNIE R. CONCEPCIONFACILITY TYPE:
740
ADDRESS:2293 LANAI AVE.TELEPHONE:
(408) 272-3155
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:33 AM
MET WITH:Administrator Wennie R. ConcepcionTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Wennie R. Concepcion. During the visit, LPA observed 1 residents and 2 staff. LPA explained the purpose of the visit.

LPA entered the home at 10:33am, and was welcomed by staff S1. As LPA was midway thru the living room, staff S2 entered living room, coming from staff rooms/ bedroom #3 area. Staff S2 was only wearing grey underwear. S2 then entered the living room and began to get changed in the living room. ADM stated S2 must have just washed his/her cloths and that this usually doesn't happen. ADM acknowledged S2 has his/her own bedroom, and he/she should have gotten changed in his/her bedroom. ADM acknowledged S2 entering the living room with just his/her underwear would create an uncomfortable environment for visitors and residents in care. ADM stated staff S2 is a reliever staff.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. While touring the backyard, LPA observed an unattended torch gun, with its propane tank attached. (Photograph was taken.) ADM stated the cooking torch gun was just used last night and the other night. ADM stated it is used to brown the meat. ADM stored the torch gun during visit, inside locked storage shed.

While touring the backyard, LPA observed a stack of boxes near the exit of the staff room and resident bedroom #1, creating an obstruction. (Photograph was taken.) LPA observed a rolled up rug in front of resident bedroom #1, creating an obstruction. (Photograph was taken.) ADM moved the rug during visit. LPA also observed the sideyard, between staff room & the living room had a narrow walk way. (Photograph was taken.) LPA advised ADM to ensure the facility is free of clutter and to ensure all passageways inside & out are free from obstruction. ADM agreed and understood. Page 1 Out of 2.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112
DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 01/09/2025 01:02 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/09/2025 at 12:18 PM
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: MARILAG'S CARE HOME
FACILITY NUMBER: 435202052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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. LPA observed a stack of boxes and a rug, creating an obstruction in the backyard, next to resident bedroom #1. LPA also observed clutter in the walkway, in the side yard, between staff room and living room. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
1
2
3
4
ADM moved the rug during visit. ADM stated she would remove all obstructions and ensure all passageways inside and out are not obstructed. ADM stated she would send LPA photo documentation showing the passage ways are clear. ADM stated she will send the plan of correction to LPA by POC date, January 10, 2025.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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. While touring the backyard, LPA observed an unattended torch gun, with its propane tank attached. ADM stated the cooking torch gun was just used last night and the other night. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
1
2
3
4
ADM secured the torch gun during visit. ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the letter to LPA by POC date, January 10, 2025.
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
TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME:Manuel Monter
TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/09/2025 01:02 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/09/2025 at 12:18 PM
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: MARILAG'S CARE HOME
FACILITY NUMBER: 435202052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above. LPA requested to review R1's admission agreement. LPA observed R1's admission agreement has pages 1-5, but does not have pages 6-8. (Page 8 containing the section for signatures .) ADM stated the admission agreement was signed, but she could not find it. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2025
Plan of Correction
1
2
3
4
ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send LPA a copy of R1's complete Admission Agreement. ADM stated she will send to LPA by POC date, January 16, 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.
SUPERVISOR'S NAME:Romeo Manzano
TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME:Manuel Monter
TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/09/2025 01:02 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/09/2025 at 12:22 PM
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: MARILAG'S CARE HOME
FACILITY NUMBER: 435202052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & interview, the licensee did not comply with the section cited above. During the inspection, LPA observed Staff S2 enter the living room, only wearing his/her underwear. ADM acknowledged Staff S2 should not get changed in the living room, and should have changed in his/her bedroom. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
1
2
3
4
ADM stated she will conduct a personal rights training with her staff, to ensure this does not happen again. ADM stated she will document all the staff who attended the training, the length of the training, and a summary of what was discussed. ADM stated she will send documentation showing the training has taken place, to LPA by POC date, January 10, 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.
SUPERVISOR'S NAME:Romeo Manzano
TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME:Manuel Monter
TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: MARILAG'S CARE HOME
FACILITY NUMBER: 435202052
VISIT DATE: 01/09/2025
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
26
27
28
29
30
31
32
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 116 degrees F in both resident bathrooms.

Fire extinguisher was serviced in 7/12/2024. 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 November 1, 2024.

LPA reviewed facility records for 3 staff and 1 residents. LPA requested to review R1's admission agreement. LPA observed the facility was using the LIC604A form for the admission agreement. LPA observed R1's admission agreement has pages 1-5, but does not have pages 6-8. (Page 8 of the LIC604A has a section for signatures for the resident/ Residents responsible party/ licensee/facility representative.) ADM stated the admission agreement was signed, but she could not find it.

LPA reviewed 1 resident medications and centrally stored medication records. LPA provided ADM with CDSS Flyer, "Important updates to Dementia Care and Miscellaneous Changes, effective January 1, 2025."

Deficiencies cited during today's visit. This report was reviewed with Administrator Wennie R. Concepcion and a copy of the signed report was provided. Appeal Rights were provided.

Page 2 Out of 2. END OF REPORT.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5