<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202394
Report Date: 02/29/2024
Date Signed: 02/29/2024 10:44:36 AM

Document Has Been Signed on 02/29/2024 10:44 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:APOLLO ADULT RESIDENTIAL CAREHOME 2FACILITY NUMBER:
435202394
ADMINISTRATOR:MARICEL BAMBAFACILITY TYPE:
735
ADDRESS:4006 BLAIRMORE COURTTELEPHONE:
(408) 841-9497
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Administrator Maricel BambaTIME COMPLETED:
10:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Maricel Bamba. During the visit, LPA observed 0 residents and 1 staff.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. While touring the backyard, LPA observed 2 sheds. The insides of the sheds are being used as storage. (Photographs were taken.)

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 110 degrees F in both resident bathrooms.

While touring facility bathroom closest to resident bedroom #1, LPA observed the flooring of the shower area was faded. LPA observed orange/yellowish stains on the shower walls. LPA observed the air extractor in the bathroom also contained dust/lint. While touring the hallway bathroom, adjacent to bedroom #3, LPA observed the shower walls with a orange/yellowish stain. LPA observed a yellow stain on the edge of the bathroom sink faucet and mirror. LPA also observed the air extractor for the hallway bathroom also had lint/dust. LPA observed the light switch for the hallway bathroom was also jutting out, exposing the inside of the light switch. (Photographs were taken.)

Fire extinguisher was serviced in May 10, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on January 9, 2024.
Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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 3
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: APOLLO ADULT RESIDENTIAL CAREHOME 2
FACILITY NUMBER: 435202394
VISIT DATE: 02/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 0 residents. Residents were attending day program during LPA's visit.

A Deficiency is being cited during today's visit, See LIC809-D. This report was reviewed with Administrator Maricel Bamba and a copy of the signed report was provided. Appeal rights were provided.

Page 2 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/29/2024 10:44 AM - It Cannot Be Edited


Created By: Manuel Monter On 02/29/2024 at 10:19 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: APOLLO ADULT RESIDENTIAL CAREHOME 2
FACILITY NUMBER: 435202394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility 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
1
2
3
4
Based on Observation, the licensee did not comply with the section cited above. LPA observed the flooring of the shower area was faded. LPA observed orange/yellowish stains on the shower walls for both bathrooms. . LPA observed the air extractor in both bahtrooms had contained dust/lint. LPA observed a yellow stain on the edge of the bathroom sink faucet and mirror. LPA observed the light switch for the hallway bathroom was jutting out, exposing the inside of the light switch. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
1
2
3
4
ADM stated she will send a written plan of action on how she will ensure the facility is clean, safe, sanitary and in good repair at all times. ADM stated she will send photo documentation showing the bathrooms are clean, sanitary and in good repari. ADM stated she will send plan of action by POC date, 03/07/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3