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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202199
Report Date: 04/18/2023
Date Signed: 04/18/2023 04:40:31 PM

Document Has Been Signed on 04/18/2023 04:40 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: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: 2DATE:
04/18/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Christian PeytonTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to conduct a case management - health checks visit. LPAs met with Administrator, Christian Peyton.

During visit, LPAs toured the facility to include the kitchen, living room, bedrooms, bathrooms, and backyard.

Around 03:40pm, LPAs entered the kitchen and observed a drawer full of knives that were not locked. LPA Dolores observed the drawer has a lock that is not working properly. Administrator secured all the knives in another locked cabinet during visit. Administrator was advised.

At 03:45pm, LPAs observed the residents bathroom on the second floor not maintained in a safe and sanitary condition with water residue build-up all along the bathtub. LPAs observed the bathroom's toilet contained dried urine along the toilet bowl. Administrator was advised.

LPAs observed dust and pet hairs all along the facility's floors to include the first floor, second floor, and staircase. Administrator was advised.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. Advisory notes provided.

This report was reviewed with Administrator, Christian Peyton and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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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Document Has Been Signed on 04/18/2023 04:40 PM - It Cannot Be Edited


Created By: Christine Dolores On 04/18/2023 at 04:14 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: SCHLOSSER HOME
FACILITY NUMBER: 435202199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2023
Section Cited
CCR
80088(e)(3)

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(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition... This requirement is not met as evidenced by:
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Licensee will ensure to clean the residents bathrooms. Licensee will send a picture via email of the bathroom to LPA by POC due date.
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Based on observation and interview the licensee did not ensure the residents bathing facilities were maintained in a safe and sanitary condition which poses an immediate health, safety, and personal rights risk to persons in care.
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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:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
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