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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202376
Report Date: 09/13/2024
Date Signed: 09/15/2024 03:51:23 PM


Document Has Been Signed on 09/15/2024 03:51 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/15/2024 02:51 PM

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

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On 9/15/2024 - at 2:45 p.m. LPA Partoza conducted an unannounced visit to amend the case management report to reflect the series of events and correct the citation that was issued at the time of the visit on 9/13/2024.

On 9/13/2024, Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcella Tarin, conducted an unannounced case management - deficiency visit and met with licensees (LICs) Ramiro Custodio and Merclo Garcia and stated the purpose of the visit.

At 11:30 a.m. LPAs Partoza and Tarin interviewed the licensee and inquired about staff who are currently working at the facility. LIC stated that the facility currently has 5 staff and 1 out of 5 lives in the facility since July 1, 2024 and did not have a fingerprint/criminal record clearance. LIC stated that staff 1 (S1) is a family and helps with care and supervision of the residents such as but not limited to activity of daily living. At the time of the visit S1 was not present and was asked by the LIC to obtain a livescan. LIC stated that S1 have not been trained for the care and supervision of the resident which is a requirement for Residential Care Facility for the Elderly (RCFE) staff.

LPA discussed with LIC that S1 is required to have a fingerprint/criminal background clearance and be associated to the facility, prior to working, residing or volunteering. LPA informed LIC that S2 cannot work or be present in any community care facility unless he/she receives a criminal record clearance from the Care Provider Management Branch (CPMB). LPA discussed with LIC the importance of training staff prior to working with RCFE residents. LIC stated that they understand and will provide training to S1.

A deficiency was cited per California Code of Regulations, Title 22 87355 (3)(b)(1) See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days x 1 individual = $500), for S1 that is residing at the facility without fingerprint and criminal background clearance. See LIC 421BG and for Title 22 87411 (c) Personnel requirement.

An exit interview was conducted during today's visit with licensee (LIC) Merclo Garcia. A copy of the report and appeals rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2024
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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