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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202100
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:01:10 PM

Document Has Been Signed on 11/15/2024 12:01 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:MASTEN CARE HOMEFACILITY NUMBER:
435202100
ADMINISTRATOR/
DIRECTOR:		JHANELLE GUICOFACILITY TYPE:
735
ADDRESS:375 FITZGERALD AVE.TELEPHONE:
(408) 846-8985
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 6CENSUS: 5DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Administrator Jhanelle GuicoTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Jhanelle Guico. During the visit, LPA observed 0 residents and 1 staff. LPA explained the purpose of the visit.

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. LPA toured the facility garage, which is being used to store a boat and other storage. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the kitchen, LPA observed one of the facility fridges does not turned on. ADM stated its currently be used as a storage space for non-perishable foods. ADM stated they are using the other fridge to store perishable foods. ADM stated she is having a technician come check the refrigerator that isn't turning on. ADM stated she has scheduled a technician to assess the refrigerator next week. ADM stated she, send LPA documentation showing the technician made a visit regarding the refrigerator.

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 108 degrees F in both resident bathrooms.

Fire extinguisher was serviced in July 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 August 14, 2024.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 2
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: MASTEN CARE HOME
FACILITY NUMBER: 435202100
VISIT DATE: 11/15/2024
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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 1 staff and 0 residents.

LPA requested a copy of the following documents;
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. LIC200, please update (i.e., new phone numbers etc), if necessary.
6. Qualifications of Administrator (Certificate)
7. LIC 309, Administrative Organization
8. Updated Lease Agreement
9. LIC610D, Emergency Disaster Plan
10. Please submit copy of surety bond

No deficiencies cited during today's visit. This report was reviewed with Administrator Jhanelle Guico and a copy of the signed report was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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