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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202281
Report Date: 02/27/2025
Date Signed: 02/27/2025 04:53:49 PM

Document Has Been Signed on 02/27/2025 04:53 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/
DIRECTOR:		ELVIRA CASIMFACILITY TYPE:
735
ADDRESS:2843 ROSARIO DRIVETELEPHONE:
(408) 802-9105
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 6DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:14 PM
MET WITH:Shirley Capati, House ManagerTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Shirley Capati House Manager LPA announced the purpose of the visit and observed 6 residents and 2 staff. ADM was called by House Manager and voicemail was left and no return call.

During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. Refrigerator temperature was measured with thermometer at 35 degrees F and freezer at 0 degrees F. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. During tour of kitchen LPA observed an unlocked drawer with knives under a grocery bag accessible to residents in care.

LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. Staff S1 tested the smoke detectors in the hallway found the smoke detector to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 114 to 115 degrees F.

LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 1/24/25 LPA reviewed Fire and Earthquake the last disaster drill was last conducted on 01/20/25.
LPA reviewed resident records for 3 residents. LPA reviewed 3 staff records House Manage reviewed the Centrally stored medication and P & I.

Deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with House Manager Shirley Capati and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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 2
Document Has Been Signed on 02/27/2025 04:53 PM - It Cannot Be Edited


Created By: Marcela Yanez On 02/27/2025 at 04:26 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: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(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.

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 by having knives in an unlocked kitchen drawer under a grocery bag which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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ADM will submit a letter of understanding regarding the regulation of other items that could pose a danger if readily available to residents shall be stored where inaccessible to residents in care. ADM will submit a written plan of correction by the POC date 02/28/25 to LPA via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
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