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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202092
Report Date: 08/14/2024
Date Signed: 08/14/2024 06:12:47 PM

Document Has Been Signed on 08/14/2024 06:12 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:THELMA'S HOMEFACILITY NUMBER:
435202092
ADMINISTRATOR/
DIRECTOR:		THELMA B. RUIZFACILITY TYPE:
735
ADDRESS:1164 CAMANO CT.TELEPHONE:
(408) 292-6631
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: 6DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Administrator Thelma RuizTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter and Marcela Yanez conducted an unannounced annual inspection visit, and met with ADM Thelma Ruiz . During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 1 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

During the visit, LPA asked staff S1 and S2 there names. LPA's checked staff S1 and S2's names on the LIS536 and their names did not appear on the list. LPA's checked S1 and S2's names on Guardian and their names are not associated with the facility. Based on record review S1 and S2 began working at the facility on June 27, 2024.

While touring the facility kitchen, LPA's observed over 2 dozen ants on the counter top and directly next to the facility kitchen sink. (Photographs were taken.) ADM stated she is planing on cleaning and has not hired a licensed professional for treatment.

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 80 degrees F, and hot water temperature was measured at 105 degrees F in both resident bathrooms.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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: THELMA'S HOME
FACILITY NUMBER: 435202092
VISIT DATE: 08/14/2024
NARRATIVE
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Fire extinguisher was serviced in March 23, 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 July 4, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records. LPA conducted interviews with 3 staff and 3 residents.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $1000 ($200 per day x 5 days = $1000) for S1 and S2 working in the facility without association.

This report was reviewed with Administrator Thelma Ruiz and a copy of the signed report was provided. Licensee refused to sign. Appeal rights were provided.

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END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2024 06:12 PM - It Cannot Be Edited


Created By: Manuel Monter On 08/14/2024 at 05:38 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: THELMA'S HOME
FACILITY NUMBER: 435202092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA's observed at least 2 dozen ants on the facility counter top, directly next to the kitchen sink. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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ADM stated she will send LPA a written plan of action on how she will ensure the facility free of ants and other insects. ADM stated she will send the written plan of action by POC date, August 21, 2024.
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA's checked staff S1 and S2's names on the LIS536 and their names did not appear on the list. LPA's checked S1 and S2's names on Guardian and their names are not associated with the facility. Based on record review S1 and S2 began working at the facility on June 27, 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Licensee will submit a plan in writing to ensure all new staff are associated to the facility prior to starting work. Licensee will also submit a plan in writing to audit their facility roster to ensure all current staff are fingerprint cleared and associated to the facility. Licensee will review section 87355 and send a statement of understand of the section and send the facility’s plan to LPA by POC due date via email.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
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