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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202281
Report Date: 01/19/2024
Date Signed: 01/19/2024 12:56:05 PM

Document Has Been Signed on 01/19/2024 12:56 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:ROSARIO HOME LLCFACILITY NUMBER:
435202281
ADMINISTRATOR:ELVIRA CASIMFACILITY TYPE:
735
ADDRESS:2843 ROSARIO DRIVETELEPHONE:
(408) 802-9105
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 6DATE:
01/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Staff member Mark AndrayaTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff member Mark Andraya (S1). During visit, LPA observed 0 residents and 1 staff.

LPA toured the facility inside out with S1 which included; the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected.

While touring the backyard, LPA observed the backyard and side fence adjacent to the garage, had multiple wooden planks missing from the fence, creating an opening to the homes next door. (Photographs were taken). LPA also observed a metal screen on the outside of the facility hallway bathroom.

While touring the facility activity room, LPA observed a shoe lace tied to the two adjacent door knobs. (LPA took photograph.) S1 stated he/she tied the door because resident R1 attempts to AWOL. S1 stated in the past R1 has AWOL'ed and jumped over the fence. S1 stated he/she needs to shower all 6 residents and he/she is the only staff at the facility from 5:30am-8:00am. S1 stated he/she tied both back door exits to keep R1 from AWOLing. (S1 stated R1 has a behavior of AWOLing thru the backdoor exits. S1 stated he/she knew tying the activity room door was wrong, but he did it to keep R1 from AWOLing as he/she was the only staff in the facility.

Based on a review of resident R1's IPP dated, 5/31/2024, R1 has a behavior of AWOL (running and walking away from site or supervision. )

Based on a review of R1's Appraisal/Needs and services plan, dated April 15, 2023, R1 has an AWOL behavior. under objective/plan, "staff to monitor R1 to prevent any AWOL incidents."

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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 6
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: ROSARIO HOME LLC
FACILITY NUMBER: 435202281
VISIT DATE: 01/19/2024
NARRATIVE
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Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 116 degrees F in both resident bathrooms.

Fire extinguisher was serviced in January 10, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. LPA requested facility fire/disaster/ drill log. The last drill conducted was on April 15, 2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident P&I records. LPA conducted interviews with 1 staff (S1) . Residents were attending day program during LPA's visit. LPA reviewed 3 resident medications and centrally stored medication records.

LPA called the ADM at 11:28am and 12:41pm. No answer. LPA left voicemail. S1 stated he/she received a text message from ADM stating she was in a doctors appointment at 10:49am. S1 showed LPA his phone with the text message.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with staff member Mark Andraya and a copy of the signed report & appeal rights were provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/19/2024 12:56 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/19/2024 at 12:02 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: ROSARIO HOME LLC
FACILITY NUMBER: 435202281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) 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 and interview, the licensee did not comply with the section cited above. LPA observed facility activity room doors were tied down with a shoe lace. S1 stated he/she tied the door to prevent R1 from leaving the facility while he/she showers the other residents. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2024
Plan of Correction
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ADM stated she will send a letter of understanding regarding the regulation, and why it's important to keep passageways free of obstruction. ADM stated she will send letter to LPA by POC date, January 20, 2024.
Type A
Section Cited
CCR
80065(a)
Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed the facility activity room's door was tied with a shoe lace. S1 stated he/she tied the door to prevent R1 from leaving the facility, while S1 was showering the other residents. S1 stated he/she knew this was wrong, but only did it because he/she was the only staff here at the facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2024
Plan of Correction
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ADM stated she will schedule staff S1 to retrain regarding personal rights of the residents and send documentation that the training has been completed. ADM stated she will also send letter of understanding regarding regulation, and why its important to have staff competent to provide the services necessary to meet individual client needs. ADM stated she will send Plan of correction to LPA by POC date, January 20, 2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/19/2024 12:56 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/19/2024 at 12:02 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: ROSARIO HOME LLC
FACILITY NUMBER: 435202281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 the backyard and side fence adjacent to the garage, had multiple wooden planks missing from the fence, creating an opening to the homes next door. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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ADM stated she will send a plan of action on how the facility will ensure the facility fence shall be in good repair for the safety and well being of the residents. ADM stated she will send the plan of action by POC date, January 26, 2024.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 in 2 Out of 2 facility bathrooms. LPA observed both bathrooms did not have their window screens. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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ADM stated she will send a plan of action on how the facility will ensure the facility window screens are in place and in good repair. ADM stated she will send LPA plan of action by POC date, 1/26/2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/19/2024 12:56 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/19/2024 at 12:02 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: ROSARIO HOME LLC
FACILITY NUMBER: 435202281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85065.5(a)(1)
Day Staff-Client Ratio
(1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Based on San Andrea's Regional Center's schedule, the facility was scheduled to have 3 staff in the morning. S1 stated he/she was the only staff present in the morning . S1 stated he locked the activity door & the other door as well, because he/she was the only staff present and needed to shower the residents. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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ADM stated she will send plan of action on how the facility will ensure it meets the staffing required as specified by the regional center. ADM stated she will send plan of action to LPA by POC date, 1/26/2024.
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Except for children's residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. S1 stated he locked the activity room exit and backyard exit, because he was the only staff present in the morning. S1 stated he/she needed to shower the residents, and by locking the backyard exits, R1 can no longer AWOL. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the letter by POC date, 1/26/2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/19/2024 12:56 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/19/2024 at 12:02 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: ROSARIO HOME LLC
FACILITY NUMBER: 435202281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review and interview, the licensee did not comply with the section cited above. R1's needs and services plan does not address R1's AWOL behavior. S1 stated R1 has a behavior of attempting to AWOL in the mornings. S1 stated that is why he/she locked the backyard exits. S1 stated R1's AWOL behavior has not been discussed with San Andreas Regional Center. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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ADM stated she will send LPA updated needs and services plan to address R1's AWOL behaviors. ADM stated she will send plan of correction to LPA by POC date, on January 26, 2024.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above. LPA reviewed facility fire/disaster drill log, and the last drill conducted was on April 15, 2023. S1 stated that was the last drill conducted. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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2
3
4
ADM stated the facility will conduct a drill and send documentation that a drill has taken place to LPA by POC date, January 26, 2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


LIC809 (FAS) - (06/04)
Page: 6 of 6