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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202199
Report Date: 01/27/2024
Date Signed: 01/30/2024 10:06:50 AM

Document Has Been Signed on 01/30/2024 10:06 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SCHLOSSER HOMEFACILITY NUMBER:
435202199
ADMINISTRATOR:APRIL MAIMONFACILITY TYPE:
735
ADDRESS:3314 LYNN OAKS DR.TELEPHONE:
(408) 982-3103
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 6CENSUS: 6DATE:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Shirley SchlosserTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual inspection to the facility. LPA met with licensee Shirley Schlosser.

Licensee stated their current census is 6 residents. 6 Out of 6 resident are ambulatory, but have added 3 more residents.

During visit, LPA accompanied by the licensee toured the facility to include the living room, dining room, kitchen, bedrooms, bathroom, garage, and backyard. Staff room was inspected, 2 bathroom were inspected. The bathroom hot water temperature was measured at 111F to 120F. Kitchen hot water temperature measured at 109.9F. The room temperature measured at 68-75F.

LPA observed the food supply is sufficient for 2 days perishable and 7 days non-perishable. Toiletries such toilet paper, paper towels, toothpaste are inspected and found to be in ample supply. Unused toxic materials such as laundry detergent, disinfectant are not accessible to residents and are in a locked cabinet.

LPA reviewed centrally stored medication record and found missing information.

LPA observed the following deficiencies; items that could pose immediate danger to clients are not stored in an inaccessible area (locked cabinets). Designated emergency exits are obstructed.

continued on page 2
LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024
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: SCHLOSSER HOME
FACILITY NUMBER: 435202199
VISIT DATE: 01/27/2024
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continued from page LIC 809 page 2 of 2
This amended report was reviewed with licensee Shirley Schlosser on 1/30/2024 and a copy of the report was provided to the licensee.
Deficiencies continued
During the tour LPA observed three individuals are currently occupying the lower rooms originally designated as office and staff bedroom. Licensee stated the occupants are family and are developmentally disabled and one of the family member is under 18 years of age.

Licensee did not have fingerprints for family members who have been residing in the facility since 12/1/2023.
Staffing needs is not met for client to staff ratio.
Licensee did not notify the department of changes with the staff when administrator ended employment.
Licensee did not have a valid administrator certificate and is operating without a certified administrator.
Fire extinguisher needs updated inspection.
Annual required visit to be continued at a later date Civil penalties for the two adult individuals will be assessed for not having a fingerprint clearance. LPA stated that any family member needs to be fingerprinted based on CCR 80019(e).

Deficiencies were observed and were not cited today's visit. The following deficiencies per California Code of Regulations, Title 22 will be cited at a later date due to time constraint.
1. 80087 (g)(1) - knives, opened cleaning solutions and laundry detergents are not locked and pose danger if readily available to clients.
2. 85065.5 (a)(1)(2) - the day staff ratio is not met following minimum staffing of no less than one direct care staff to three clients.
3. 85064.3(e) - licensee did not have a current administrator certificate. Licensee stated her administrator certificate expired in year 2000.
4. 80063 (a) - licensee lacked the general supervision of the licensed facility concerning the operation and hiring qualified administrator and care staff
5. 80019 (e) - licensee did not obtain fingerprint clearance for 2 adult family member residing in the facility. LPA informed licensee that Civil Penalties will be assessed for the two adult individuals. Family member has to leave the facility until fingerprint clears.
6. 80061(e)(4) - licensee did not notify the department of changes when administrator ended employment on 12/1/2023.
7. Advisory was given for expired fire extinguisher inspection, the flower pot obstructing emergency exit was immediately corrected by the licensee during the visit in keeping with the facility's emergency and disaster plan. Additional advisory for record keeping and filing was also given.
This amended report was reviewed with licensee Shirley Schlosser and a copy of the report was provided to the licensee.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC809 (FAS) - (06/04)
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