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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202331
Report Date: 04/23/2024
Date Signed: 04/23/2024 02:06:41 PM

Document Has Been Signed on 04/23/2024 02:06 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:SVS GILROY ADULT DAY PROGRAMFACILITY NUMBER:
435202331
ADMINISTRATOR/
DIRECTOR:		ALISON NOBLEFACILITY TYPE:
775
ADDRESS:7101 MONTEREY ROADTELEPHONE:
(408) 843-9630
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 60CENSUS: 48DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Michelle PagsisihanTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a required - 1 year annual inspection. LPA met with Program Director (PD), Michelle Pagsisihan.

LPA toured the facility with PD to include the entrance, all activity rooms, office, staff break room, kitchen, bathroom, and exterior. During visit, LPA observed the clients participating in various activities. All fire exit routes were free and clear of obstruction. Sharp objects, chemicals, and disinfectants observed locked. Facility temperature maintained at 72 degrees Fahrenheit. Fire extinguisher last serviced on 12/05/2023. Facility exit routes posted throughout the facility. Posters observed to include if you see something say something, activities calendar, and personal rights. First Aid kit observed complete to include a manual, scissors, tweezers, gauze, and bandages. Hot water temperature maintained at 116 degrees. Facility has an infection control plan and emergency disaster plan. Facility conducts emergency disaster drills monthly.
6 resident records reviewed to include a signed admission agreement, medical assessment, TB result, IPP, consent form, and personal rights form. 1 out of 6 residents file was missing an admission agreement, medical assessment, TB result, consent form, and personal rights form. Staff stated the resident was admitted to the day program about 1 year ago and was transferred from another SVS location. PD was advised. 5 staff records were reviewed to include a 1st aid certification, fingerprint clearance, job application, health screening, TB result, employee rights, and staff training. 5 out of 5 staff are fingerprint cleared. 2 out of 5 staff obtains a first aid certification. 6 residents and 5 staff members were interviewed.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Program Director, Michelle Pagsisihan and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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 04/23/2024 02:06 PM - It Cannot Be Edited


Created By: Christine Dolores On 04/23/2024 at 12:25 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: SVS GILROY ADULT DAY PROGRAM
FACILITY NUMBER: 435202331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82070(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. A separate, complete, and current record shall be maintained at the program site for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 6 counts by a client (C1) not having a medical assessment, TB result, admission agreement, consent form, and personal rights form on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Licensee plans to obtain all required documents in this section for client (C1). Licensee will submit a statement of understanding of the section cited above and C1's documents obtained. Licensee will submit the POC via email by POC due date.
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
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