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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202171
Report Date: 12/21/2023
Date Signed: 12/22/2023 08:28:13 AM

Document Has Been Signed on 12/22/2023 08:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME:TERRA COTTA HOMEFACILITY NUMBER:
435202171
ADMINISTRATOR:ANGELINA DOOLABHFACILITY TYPE:
735
ADDRESS:3233 TERRA COTTA DR.TELEPHONE:
(408) 270-7440
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 6CENSUS: 6DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Licensee Representative/Administrator Manharlal DoolabhTIME COMPLETED:
07:00 PM
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On 12/21/23, Licensing Program Analysts (LPA) L. Salazar and LPA Doucette arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPAs were greeted by Staff, stated the purpose of the visit and was allowed entry into the facility. Administrator arrived to the facility a few minutes later. Staff provided a tour of the facility inside and out. Licensee Representative/Administrator on record is Manharlal Doolabh, Certificate #6003965735 Expires 04/2024.

LPAs observed 6 residents in care at the time of visit. Facility is a 6 bedroom / 2 bathroom home. 4 bedrooms are designated for residents in care. 2 out of 6 residents have their own bedrooms, 4 out of the 6 residents share bedrooms. Two bedrooms are designated for four(4) live-in staff. Bathroom #1 is designated for Staff and Bathroom # 2 is designated for all residents in care.

LPA's observed the following during the tour:
Bedroom #1 - Resident R1's room has broken dresser drawer knobs.
Bedroom #2 - Resident R2's room has a thin mattress with no box spring, door and door frame are observed to be dirty and need to be repainted or deep cleaned.
Bedroom #3 - Resident R3's room has a dresser with broken knobs.
Bedroom #4 - Resident's R4's room had a dresser facing the wall, making the drawers inaccessible.
No resident room was observed to have personal lighting. Facility temperature was 64 degrees F. Facility turned heater on upon LPA's arrival.

Bathroom #1 was observed to have rust along outside base of the bathtub. The door and door frame are observed to be dirty and need to be repainted or deep cleaned. Bathroom #2 was observed to have a wet and slippery tile floor. No protective device or non-skid mat was observed in the all tiled bathroom. Ceiling was observed to be wet with condensation, toilet paper holder is broken and toilet paper was observed to be on the back of the toilet. Bathroom tile was broken on the base of the floor in the shower, bathroom light fixture is rusted, wall light switch plate has mildew. Flooring is broken around the toilet causing a tripping hazard. No covered trash can was observed. Exhaust fan did not adequately clear the condensation in the bathroom. Hot water temperature tested at 111.3 degrees F. (Continued on LIC 809-C)
SUPERVISORS NAME: Melinda Medina
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: TERRA COTTA HOME
FACILITY NUMBER: 435202171
VISIT DATE: 12/21/2023
NARRATIVE
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(Continued from LIC 809)

Hallway walls are observed to be dirty and need to be painted. Light fixture in the hall ceiling, next to Bathroom #2, was observed to be rusted. 4 out of the 6 Hallway drawers under the cabinet were observed in disrepair, broken and with drill holes where locks were removed. Living room , dining room , hallway and kitchen walls were observed to be missing paint and in disrepair.

Medications were observed to be locked in a kitchen cabinet . Cleaning supplies were observed to be locked in the office/laundry room closet. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. Resident snacks were locked. Administrator removed lock during visit. There are no residents with Restricted Health conditions in the facility.

Carbon monoxide and smoke detectors were tested and observed to be operational. Night lights were observed in the hallways. Fire Extinguisher was observed with a service date of 06/22/23. First aid kit was observed and contained all required items.

LPA Doucette toured the exterior and back yard. LPA observed boxes stacked on the back patio along with furniture that is in disrepair. There is no resident outdoor seating area observed for residents in care. LPA observed a pool which was gated, locked and inaccessible to residents in care. Several screens on the back windows of the house are in disrepair. Side gate was self-closing and self-latching.

A sample of resident files were reviewed and observed to have update emergency contacts, Admission agreement, and current physician report/individual performance plans (IPP). A sample of P&I records were observed to be accurately logged and documented. Staff files were also reviewed and observed to have current First Aid/CPR, and required forms. Staff are fingerprinted clear and associated to the facility.

Quarterly Emergency Disaster Drill logs were observed for staff. LPA observed on the LIC 610D (Emergency Disaster Plan) with emergency numbers were observed posted in the kitchen.

LPA Doucette toured the exterior and back yard. LPA observed boxes stacked on the back patio along with furniture that is in disrepair. There is no resident outdoor seating area observed for residents in care. LPA observed a pool which was gated, locked and inaccessible to residents in care. Several screens on the back windows of the house are in disrepair. Side gate was self-closing and self-latching.

Based on today’s visit, a deficiency is being cited, per California Code of Regulations, Title 22, Division 6, Chapter 8 on the attached 809D. If not corrected, this poses a potential risk to residents in care.

An exit interview was conducted with Licensee. A copy of this report and appeal rights were discussed and provided to . A plan of correction was developed by licensee and reviewed with LPAs.

SUPERVISORS NAME: Melinda Medina
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2023 08:28 AM - It Cannot Be Edited


Created By: Lisa Salazar On 12/21/2023 at 05:52 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
,
, CA

FACILITY NAME: TERRA COTTA HOME
FACILITY NUMBER: 435202171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
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.

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 based on the repairs listed in the report, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2024
Plan of Correction
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Licensee agrees to fix all the repairs listed on the 809 by POC due date 1/22/24 via photo submission to LPA Salazar.
Type B
Section Cited
CCR
80087(b)(1)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs.

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 in not having a non slip mat in an all tile bathroom which was wet, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Licensee agrees to supply a non slip mat for the all tile bathroom by POC due date 01/05/24. Licensee send proof via photo submission to LPA Salazar.
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:Melinda Medina
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/22/2023 08:28 AM - It Cannot Be Edited


Created By: Lisa Salazar On 12/21/2023 at 05:52 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
,
, CA

FACILITY NAME: TERRA COTTA HOME
FACILITY NUMBER: 435202171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(19)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition.

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 in the kitchen refrigerator deteriorating and rusting, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Licensee agrees to replace the kitchen refrigerator by POC due date 01/5/24 via photo submission to LPA Salazar.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Melinda Medina
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
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