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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202242
Report Date: 02/21/2024
Date Signed: 02/26/2024 08:26:55 AM

Document Has Been Signed on 02/26/2024 08:26 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:EASTER HOMEFACILITY NUMBER:
435202242
ADMINISTRATOR:FLAMINGO R. LIGUTOMFACILITY TYPE:
735
ADDRESS:400 EASTER AVE.TELEPHONE:
(408) 263-8133
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 6CENSUS: 5DATE:
02/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:59 PM
MET WITH:Eddilyn RealistaTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mita Partoza, conducted a required annual visit to the facility and met with Eddilyn Realista designated administrator herein referred to as DADM. At the time of the visit, administrator herein referred to as ADM Flamingo Ligutom was on vacation. DADM presented the LIC 308 designating 2 staff in her absence.

Current facility census count 5 residents. At the time of the visit all residents were home. 4 out of 5 residents are ambulatory and 1 non ambulatory

During the visit, LPA toured the facility and inspected the living room, dining room, kitchen, 3 resident bedrooms, 1 bathrooms and 2 staff room, garage and the exterior perimeter.

LPA observed sufficient supply of food for 7 days that is non-perishable and 2 days perishable food.
The laundry area is located in the garage accessible to residents. Inside the garage LPA observed laundry detergent and other toxic materials that are not locked. Per DADM, the residents can access the garage if accompanied by a staff. The door going to the garage from the kitchen does not lock. Smoke alarms were tested and are in good working condition.

The water temperature was measured inside bathroom and kitchen and temperature ranges from 105 degrees Fahrenheit to 110 degree Fahrenheit. The residents room was clean and linens were clean. Sliding doors from the resident's room to the exterior was accessible. Room temperature in the facility ranges from 68 degree Fahrenheit to 72 degree Fahrenheit.

Continued to page 2 LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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
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: EASTER HOME
FACILITY NUMBER: 435202242
VISIT DATE: 02/21/2024
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continued from page 1 of LIC 809
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LPA observed water damage/leak on the roof of the covered patio and the wall of resident's room, motor oil located near the gate and at side of the facility, garbage bins are obstructing the ramp towards the side gate entrance an open compost bucket that attracts flies. LPA observed a large bag of Miracle Grow (fertilizer) in the backyard. Gardening chemicals under a stairs from the outdoor and accessible to residents.

The facility has fire sprinklers and disaster plan training is up to date. 2 staff records were reviewed along with 2 client's record. Client's record and medication records were reviewed and was found to be up to date.

The following deficiencies were cited during today's visit per California Code of Regulation (CCR) title 22.
  1. 80087(g)(1)(c)- Buildings and Grounds - Storage areas for disinfectants, cleaning solutions, and poisons shall be locked.
  2. 80087(d) Buildings and Grounds- All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
  3. 80076(a)(18) - Food Service - Foods shall be protected against contamination, and contaminated foods shall be discarded immediately
  4. 80087(a) - Buildings and Grounds: The facility shall be kept clean, sanitary and in good repair at all times.

At approximately 5:41 p.m., LPA was able to reach the facility administrator Flamingo Ligutom and informed her of the immediate attention necessary to the above citations. ADM stated she understood and will address deficiencies accordingly. ADM is currently out of the country and DADM was present during the call.

An exit interview was conducted with designated administrator (DADM) Eddilyn Realista a copy of the report and appeals rights were provided.

END OF REPORT
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/26/2024 08:26 AM - It Cannot Be Edited


Created By: Maria Partoza On 02/21/2024 at 06:02 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: EASTER HOME
FACILITY NUMBER: 435202242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(18)
80076(a)(18) - Food Service - Foods shall be protected against contamination, and contaminated foods shall be discarded immediately. 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, rotting food that are used for compost is not covered therefore attracts flies and rodents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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Licensee stated that food safety will be prioritized and will send a plan of correction (POC) on the due date.
Type A
Section Cited
CCR
80087(a)
80087(a) - Buildings and Grounds: The facility shall be kept clean, sanitary and in good repair at all times.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on oservation the licensee did not comply with the section cited above. LPA observed that there was water damage on the ceiling of the covered patio by the resident's room. Licensee needs to maintain the facility's integrity from possible damage to structure which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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Licensee stated that a plan of correction will be submitted on the due date. Licensee stated that they are in the process of hiring a contractor to address the issue.
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: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/26/2024 08:26 AM - It Cannot Be Edited


Created By: Maria Partoza On 02/21/2024 at 06:14 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: EASTER HOME
FACILITY NUMBER: 435202242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)(c)
80087(g)(1)(c)- Buildings and Grounds - Storage areas for disinfectants, cleaning solutions, and poisons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation the licensee did not comply with the section cited above toxic materials but not limited to laundry detergent, motor oil and paint removers are easily accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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Licensee stated the plan of correction (POC) will be submitted on due date. Licensee stated that chemicals will be put in a locked storage and will not be mixed with non-perishable foods in the garage to ensure the safety of residents in care.
Type A
Section Cited
CCR
80087(d)
80087(d) Buildings and Grounds- All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. 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. LPA observed 3 large garbage bins, and gardening tools that are obstructing the ramp which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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Licensee stated the the plan of correction (POC) will be submitted on the due date. Items that are obstructing the ramp and passageways will be clear from obstruction.
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: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4