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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202172
Report Date: 10/09/2024
Date Signed: 10/09/2024 04:29:04 PM

Document Has Been Signed on 10/09/2024 04:29 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:STURLA CARE HOMEFACILITY NUMBER:
435202172
ADMINISTRATOR/
DIRECTOR:		DUMANTAY, MARJORIEFACILITY TYPE:
735
ADDRESS:2644 STURLA DRTELEPHONE:
(408) 818-0134
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Marjorie DumantayTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Marjorie Dumantay, Administrator/Licensee.

During visit, LPA Marrufo toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days.

LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. LPA tested the smoke detectors in the hallway and three resident bedrooms and found the smoke detector to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks were 110 F and 119 F.

LPA toured the outside area and found the exits to be clear of obstructions. LPA reviewed Personal and Incidental Money Logs for the 4 out of 4 residents whose money is kept by the facility and found all the Personal and Incidental Money Logs to be balanced.

LPA reviewed resident records for 6 out of 6 residents. 6 out of 6 residents were missing the Safeguard for Property and Valuables Form. LPA reviewed 5 staff records and found them to be complete.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information. This report was reviewed with Marjorie Dumantay and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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Document Has Been Signed on 10/09/2024 04:29 PM - It Cannot Be Edited


Created By: David Marrufo On 10/09/2024 at 04:16 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: STURLA CARE HOME
FACILITY NUMBER: 435202172

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82070(b)(13)
82070 Client Records (b) Each record must contain information including, but not limited to, the following: (13) In those cases in which the licensee handles the client's cash, an account of the client's cash resources, personal property, and valuables entrusted as specified in Sections 82026(h) through (k).


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 in 6 out of 6 reviewed resident records, which did not contain a Safeguard for Property and Valuables Form, which poses a potential personal rights risk to persons in care.
POC Due Date: 10/16/2024
Plan of Correction
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Licensee agrees to submit completed copies of Safeguard for Properties and Valuables Forms for 6 out of 6 residents to CCL by POC date.
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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


LIC809 (FAS) - (06/04)
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