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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202342
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:13:58 PM

Document Has Been Signed on 03/11/2025 04:13 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:LA CROSSE HOME INCFACILITY NUMBER:
435202342
ADMINISTRATOR/
DIRECTOR:		PERLA CAYABYABFACILITY TYPE:
735
ADDRESS:256 LA CROSSE DRIVETELEPHONE:
(408) 499-3708
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 6CENSUS: 6DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator Perla CayabyabTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Marcela Yanez and Manuel Monter conducted an unannounced Required 1 Year visit and met with Perla Cayabyab, Administrator. LPAs announced the purpose of the visit. LPAs observed 4 residents and 4 staff.

During visit, LPAs toured the facility inside and out. LPAs toured facility 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. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature measured with thermometer at 42 degrees F and freezer at 3 degrees F. Room temperature was measured at 71 degrees F.

During tour LPAs observed activity area with puzzles, tread mill and games for resident. LPAs toured 4 resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. A staff room was also toured LPAs toured 3 resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer between 105-109 degrees F.

LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 02/05/2025. LPA reviewed Fire and Earthquake log and the last disaster drills were last conducted on 03/10/2025. ADM tested the smoke detector and found the smoke detector to function properly when tested.


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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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 3
Document Has Been Signed on 03/11/2025 04:13 PM - It Cannot Be Edited


Created By: Marcela Yanez On 03/11/2025 at 03:46 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: LA CROSSE HOME INC
FACILITY NUMBER: 435202342

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 0bservation, interview and record review, the licensee did not comply with the section cited above R3 is above 60 years old and does not have a current Physicians report last date was 12/13/2022. LPA asked if they had a current appointment for R3 and ADM stated "I know I missed that". ADM stated she will make and appointment to get a current Physicians report for R3. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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ADM stated she will provide a letter of understanding of the regulation and ADM states she will make an appointment and provide a new physicians report by the POC date 03/18/2025.
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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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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: LA CROSSE HOME INC
FACILITY NUMBER: 435202342
VISIT DATE: 03/11/2025
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LPA reviewed resident records for 3 residents. Based on record review R3 is above 60 years old and has a Physicians report last date was 12/13/2022. LPA asked if they had a current appointment for R3 and ADM stated "I know I missed that". ADM stated she will make and appointment to get a new Physicians report for R3. LPA reviewed 3 staff records. ADM reviewed the Centrally Stored Medication Record and P & I for 3 residents.

Deficiency was cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Perla Cayabyab and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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