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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202307
Report Date: 04/08/2024
Date Signed: 04/09/2024 08:06:22 AM

Document Has Been Signed on 04/09/2024 08:06 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SIESTA VISTA HOMEFACILITY NUMBER:
435202307
ADMINISTRATOR/
DIRECTOR:		MARIA CECILIA CLARIDADFACILITY TYPE:
735
ADDRESS:15860 SIESTA VISTA DRIVETELEPHONE:
(408) 258-5518
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 3DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:MARIA CECILIA CLARIDADTIME VISIT/
INSPECTION COMPLETED:
11:59 AM
NARRATIVE
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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 observed 2 staff in the facility, and all 3 residents went to day program. LPA checked 2 resident record files and 3 staff record files.

LPA toured the facility inside and out with ADM. Facility license, Administrator Certificate, and Personal Rights posters were observed posted at the facility.

Living room, kitchen, dinning room and two restrooms were inspected. 5 single resident bedrooms, 2 restrooms, 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 115 degree F in facility. The temperature of the refrigerator was at 38 degree F and the temperature of the freezer was at 0 degree F. First Aid box, flash lights and night lights were observed in the facility. The last time the facility conducted the emergency drill was on 3/3/2024.

Fire extinguisher was serviced on 05/01/2023. 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. LPA observed an unused empty swimming pool with a cover and locked metal surrounding fence. Two sheds were observed in the backyard as storage rooms.

Deficiencies noted today See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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 2
Document Has Been Signed on 04/09/2024 08:06 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 04/08/2024 at 11:43 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
, 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: 04/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 that 1 out of 5 resident bedroom was missing window screen which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to install the window screen.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that resident admission agreements were observed without signature of client//family which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to have client/family to sign the admission agreement.
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: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024


LIC809 (FAS) - (06/04)
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