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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202199
Report Date: 01/30/2024
Date Signed: 02/01/2024 06:04:42 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/01/2024 06:04 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: DATE:
01/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Shirley SchlosserTIME COMPLETED:
05:30 PM
NARRATIVE
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The purpose of this case management is to amend the annual required inspection conducted on 1/28/2024 wherein the Department discussed with licensee/administrator (LIC/ADM) the deficiencies. Due to time constraint LIC 809-D was not issued. Today 1/30/2024 LIC 809-D is being issued and LIC 809-C page 2 of the annual required visit is amended. Copies of the amended and LIC 809-D are provided to LIC/ADM.

On 1/27/2024, LPA observed the following deficiencies:
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.
Technical advisory were provided for expired fire extinguisher inspection tag, flower pot obstructing emergency exit door which licensee corrected during the visit in keeping with the facility's emergency and disaster plan, record keeping and filing.

LPA conducted exit interview and Appeal Rights was provided to the LIC/ADM Shirley Schlosser.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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 4
Document Has Been Signed on 02/23/2024 10:31 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/01/2024 06:06 PM


Created By: Maria Partoza On 01/30/2024 at 09:57 AM
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SCHLOSSER HOME
FACILITY NUMBER: 435202199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2024
Section Cited
CCR
80087(g)(1)

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This is an amended report from visit 1/30/24 (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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Licensee stated that plan of correction (POC) will be submitted on the due date. Licensee stated that all knieve and cleaning solutions will moved to a locked cabinet.
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This requirement is not met as evidence by:

Based on observation licensee did not ensure knives and opened cleaning solutions were locked, which poses an immediate health and safety risk to residents in care.
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Type A
01/31/2024
Section Cited
CCR85065.5(a)(1)

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(a) Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met: (1) For Regional Center clients, staffing shall be maintained ... but no less than one direct care staff to three such clients.
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.Licensee stated the plan of correction (POC) will be submitted at the due date. Licensee stated that he/she will have another staff to comply with regulations.
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This requirement is not met as evidence by: Based on observation and interview, licensee did not ensure staffing ratio is met for Regional Center clients. Staff ratio during visit was 1 is to 6 clients. Which poses an immediate health and safety rish to residents 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:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/23/2024 10:31 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/01/2024 06:07 PM


Created By: Maria Partoza On 01/30/2024 at 11:42 AM
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SCHLOSSER HOME
FACILITY NUMBER: 435202199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2024
Section Cited
CCR
85064.3(e)

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This is an amended report from visit on 1/30/2024
(e) To apply for recertification after the expiration date of the certificate, but within four (4) years of the certificate expiration date, the certificate holder shall submit to the Department's Administrator Certification. This requirement is not met as evidenced by:
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Licensee stated a plan of correction will be submitted on the due date. Licensee stated he/she will try to hire an administrator until licensee can get recertified.
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Based on inteview and record review licensee did not apply for recertification when administrator certificate expired in year 2000, which poses an immediate health and safety risk to persons in care.
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Type A
01/31/2024
Section Cited
CCR80063(a)

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Accountability(a)The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation. This requirement is not met as evidenced by:
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Licensee stated a plan of correction (POC) will be submitted on the due date. Licensee stated that he/she will oversee all aspects of the facility and ensure compliance.
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Based on observation, record review and interview, licensee did not provide general supervision concerning the operation of facility and staff, which poses and safety risk hazards 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:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/23/2024 10:32 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/01/2024 06:08 PM


Created By: Maria Partoza On 01/30/2024 at 01:24 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SCHLOSSER HOME
FACILITY NUMBER: 435202199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2024
Section Cited
CCR
80019(e)

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This is an amended report from 1/30/24
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility.
This requirement is not met as evidenced by:
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LIcensee stated that plan of correction (POC) will be submitted on due date. Licensee stated that once adult individuals residing in the facility have been fingerprinted he/she will notify licensing.
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Based on interview, licensee did not submit a fingerprint clearance to adult individuals residing in the facility, which poses health and safety risk to persons in care.
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Type A
01/31/2024
Section Cited
CCR80061(e)(4)

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Reporting requirements (e) The items below shall be reported to the licensing agency within 10 working days following the occurrence. (4) Any changes in the plan of operation which affect the services to clients.

This requirement is not met as evidenced by:
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 Licensee stated that plan of correction (POC) will be submitted on due date. Licensee stated that he/she will notify the department of any changes and when administrator ends their employment in the future.
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Based on observation, record review and interview, licensee did not notify the Department when the administrator/staff ended their employment on 12/1/2023, which poses health and safety risks 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:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
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