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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202331
Report Date: 04/16/2025
Date Signed: 04/16/2025 02:35:17 PM

Document Has Been Signed on 04/16/2025 02:35 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: 42DATE:
04/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Michele PagsisihanTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Program Director (PD), Michele Pagsisihan.

During visit, LPA toured the day program with PD to include the activity rooms, office, kitchen, bathroom, staff break room, storage, laundry room, office, and exterior. Clients observed participating in activities and observed supervised by staff.

LPA observed the exit door leading into the back alleyway was obstructed by multiple large bags filled with garbage and a mattress bed. LPA obtained a photograph of the area which shows piles of large garbage bags stacked in front of the exit door and besides the dumpster bin. PD stated their dumpster did not get picked up last week, in which PD reached out to the facility's program office to schedule a pick up. PD states the dumpster bin was emptied today which was why the dumpster bin was observed empty. It was stated that the facility's neighbors are businesses, one including a restaurant, who fills the facility's dumpster bin leaving no room for their garbage, resulting in the facility stacking their garbage in front of the door and besides the garbage bin. PD states the cleaning person (who is a third-party vendor) is responsible for locking their dumpster bin daily, however, thinks the dumpster is not being locked which opens the opportunity for the neighbors to place their garbage in their dumpster bin. Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: SVS GILROY ADULT DAY PROGRAM
FACILITY NUMBER: 435202331
VISIT DATE: 04/16/2025
NARRATIVE
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PD was advised that it is the facility's responsibility to ensure the exit areas are free and clear of obstruction and that the facility grounds is clean, safety and sanitary.

Facility temperature maintained at 74 degrees F. Fire extinguishers last serviced on 12/03/2024. Hot water temperature in the women's bathroom maintained at 114.8 degrees F. Sharp objects, chemicals and disinfectants observed in separate areas and locked. Kitchen is supplied with a first aid kit.

Facility does not have a carbon monoxide detector. Staff contacted the third party vendor who inspects the facility's alarm system who confirmed the smoke detector does not include a carbon monoxide detector.

3 client records were reviewed. 3 out of 3 client files contained an admission agreement, consent form, personal rights, medical assessment, TB result, ID/emergency contact information, and updated needs and services plan and/or IPP.

3 staff files were reviewed. 3 out of 3 staff files contains a fingerprint clearance, health screening, TB result, and active first aid certification.

Facility has an emergency disaster plan. Emergency drills are being completed quarterly and the last drill was completed in January and February 2025.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Program Director, Michele Pagsisihan and a copy of the report and appeal rights were provided.

Page 2 of 2.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/16/2025 02:35 PM - It Cannot Be Edited


Created By: Christine Kabariti On 04/16/2025 at 01:55 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: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 wherein the licensee did not ensure a carbon monoxide detector is present in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Licensee will purchase carbon monoxide detectors, ASAP. Licensee will submit a copy of the receipt and a photograph of where the carbon monoxide detectors are located in the facility. Licensee will submit these items to LPA Kabariti via email by 04/17/2025.
Type A
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site 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 and interview, the licensee did not comply with the section cited above wherein LPA observed piles of garbage bags on the floor outside the facility's exit door which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Licensee will ensure all the garbage bags will be disposed of properly, ASAP. Licensee will send a picture of the area to LPA Kabariti via email by 04/17/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/16/2025 02:35 PM - It Cannot Be Edited


Created By: Christine Kabariti On 04/16/2025 at 01:55 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: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(c)
Buildings 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 wherein the licensee did not ensure the exit door was clear of obstruced as LPA observed it was blocked by piles of garbage bags which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Licensee will clear the garbage bags blocking the exit door, ASAP. Licensee will also print out and post signs on the exit doors as a reminder to not block the exit ways. Licensee will send a picture of the area and signs to LPA Kabariti via email by 04/17/2025.
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.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
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