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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202412
Report Date: 12/26/2023
Date Signed: 12/26/2023 05:16:34 PM


Document Has Been Signed on 12/26/2023 05:16 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MERIDIAN MANOR 3 SPECIAL RES FAC FOR ELDERLY(RCFE)FACILITY NUMBER:
435202412
ADMINISTRATOR:DAVE MAGNOFACILITY TYPE:
740
ADDRESS:345 BURNETT AVE.TELEPHONE:
(408) 772-0339
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:4CENSUS: 4DATE:
12/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Dave MagnoTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Dave Magno.

LPA observed 4 residents and 3 staff at facility. LPA reviewed 4 resident files and 4 staff files.

Facility license, Administrator Certificate, and personal right posters were observed at main entrance.

LPA toured the facility with ADM inside and out. LPA inspected living room, dinning area, kitchen. There are 2 restrooms, 4 resident rooms in facility. Two days perishable foods and seven days non perishable foods were observed sufficient. Room temperature was observed at 73 degree F, hot water temperature was observed at 113 degree F. Temperature of refrigerator was measured at 40 degree F, and temperature of freezer was observed at 0 degree F. Medication cabinet, Knives closet and cleaning products closet were observed locked. No night lights was observed in the hallway, and no flash lights was available in the facility.

Fire extinguisher was serviced on 1/11/2023. The facility is equipped with fire alarm and carbon monoxide detectors. Smoke detector alarm system was tested, and was working fine. First Aide Box was observed available in the facility. Front yard and backyard were inspected. There was no obstruction to block the walkways. A detached garage was observed with 3 cars at the back yard. Two staff live-in rooms were observed at the backyard. ADM stated the detached garage and two staff rooms existed when ADM bought the property. The facility sketch shows the detached garage and two staff live-in room.

Facility last fire and emergency drill was conducted on 12/01/2023.

No citation was issued today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2023
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 2


Document Has Been Signed on 12/26/2023 05:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: MERIDIAN MANOR 3 SPECIAL RES FAC FOR ELDERLY(RCFE)
FACILITY NUMBER: 435202412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(h)
Maintenance and Operation
(h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff. Open-flame lights shall not be used.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview conducted with Administrator, the licensee did not comply with the section cited above in that there was no flashlight was observed in the facilty which poses/posed a potential health, or safety risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Administrator stated the facility will submit a plan of correction by the POC due date to buy flashlights and place in the facility.
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview conducted with ADM, the licensee did not comply with the section cited above in that there was no night-light was observed in the hallway which poses/posed a potential health or safety risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Administrator stated the facility will submit a plan of correction by the POC due date to buy night-lights to install in the hallway.
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 ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2023
LIC809 (FAS) - (06/04)
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