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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202307
Report Date: 04/19/2023
Date Signed: 04/19/2023 04:55:00 PM

Document Has Been Signed on 04/19/2023 04:55 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SIESTA VISTA HOMEFACILITY NUMBER:
435202307
ADMINISTRATOR:MARIA CECILIA CLARIDADFACILITY TYPE:
735
ADDRESS:15860 SIESTA VISTA DRIVETELEPHONE:
(408) 258-5518
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 4DATE:
04/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:MARIA CECILIA CLARIDAD, ADMTIME COMPLETED:
04:18 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) MARIA CECILIA CLARIDAD. LPA checked 4 resident record files (R1 - R4) and 5 staff record files (S1 - S5). 4 residents (R1 - R4) and 2 staff (S1 - S2) were interviewed.

LPA toured the facility inside and out with ADM. Facility license, Administrator Certificate, and Personal Rights posters were observed posted at the facility. A screening station with masks, hand sanitizer, glove, thermometer and visitor log book was observed at the main entrance.

Living room, kitchen, dinning room and two restrooms were inspected. 4 single resident bedrooms, 1 shared resident bedroom, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 112 degree F in facility. Cloth towel were observed at kitchen. No night light was observed in the hall way.

Fire extinguisher was serviced on 05/03/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by staff, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Exit interview was conducted with ADM. This report was provided to ADM for signature. LIC809-D, LIC9102, and Appeal Rights were attached.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023
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 04/19/2023 04:55 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 04/19/2023 at 03:34 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: SIESTA VISTA HOME
FACILITY NUMBER: 435202307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)

95088 Fixtures, Furniture, Equipment and Supplies.
(e)(2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2023
Plan of Correction
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Licensee agreed to submit Plan of Correction by the POC due date to add the night lights in the hallway.
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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023


LIC809 (FAS) - (06/04)
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