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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202412
Report Date: 12/27/2024
Date Signed: 12/27/2024 01:33:22 PM

Document Has Been Signed on 12/27/2024 01:33 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:MERIDIAN MANOR 3 SPECIAL RES FAC FOR ELDERLY(RCFE)FACILITY NUMBER:
435202412
ADMINISTRATOR/
DIRECTOR:		DAVE MAGNOFACILITY TYPE:
740
ADDRESS:345 BURNETT AVE.TELEPHONE:
(408) 772-0339
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Jessie Gamboa and Leny GamboaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On December 27, 2024, at 11:25 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the DSP, Jessie Gamboa and disclosed the purpose of the inspection. The DSP informed the LPA that the facility currently has 4 residents in care and 3 staff members present at the time. Leny Gamboa, Lead Staff arrived shortly after.

At 11:32 AM, the LPA initiated a walk-through of the facility, accompanied by the DSP.

LPA inspected the kitchen and found it clean, with no food preparation or cooking in progress at the time. LPA checked the appliances and observed them in working order. LPA inspected the refrigerator and pantry cabinets and observed enough supplies of fresh perishable food for (2) days and nonperishable staples for (7) days. No expired food and no stored medications were noticed.

There are (4) bedrooms and (1) bathroom designated for residents' use. LPA inspected all (4) resident rooms and found them clean, well-lit, and equipped with the required furniture. LPA inspected the common resident bathroom and found it clean, sanitary, and in good working condition. It contained soap, grab bars, a trash can, non-slip mats, a shower chair, and a shower bed. The hot water temperature at the sink faucet was measured at 109.8°F. LPA inspected the storage closet in the hallway and observed it containing clean linens and towels for residents’ use.

LPA inspected the dining area and observed it clean, with all the furniture in good repair. LPA inspected the fire extinguisher mounted on the wall in the kitchen/eating area and found it was fully charged with a last service tag of 01/08/2024. The DSP tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. LPA inspected the living room/activity area and observed residents sitting there, listing to music and watching TV, with (2) caregivers assisting the residents.

Continued on LIC809-C

April CowanTELEPHONE: (650) 266-8889
Kiran JainTELEPHONE: (650) 416-4836
DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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 2
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: MERIDIAN MANOR 3 SPECIAL RES FAC FOR ELDERLY(RCFE)
FACILITY NUMBER: 435202412
VISIT DATE: 12/27/2024
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LPA reviewed (5) staff personnel records and (4) resident records. The LPA observed that 4 of 4 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening, and confirmed that 5 of 5 staff members are associated with the facility.

LPA observed a locked centrally stored medication cabinet located inside the kitchen/eating area. Medications were organized in separate bins for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete.

LPA inspected the first aid kit and observed it fully stocked.

LPA reviewed Emergency Drill Logs and observed Fire and Earthquake Emergency Disaster Drills were conducted every month, with the most recent drill completed on 12/16/2024.

The DSP counted Resident P&I money in front of the LPA and records indicated the correct amount.

The following updated forms are requested to be submitted to CCLD by 01/03/2025:

  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • LIC 400: Cash Resources Affidavit
  • Surety Bond
  • Certificate of Liability Insurance
  • Current Property Lease Agreement
  • Administrator Certificate(s)

No deficiencies were cited during today's visit.

An exit interview was conducted. A copy of this report was left with the Lead Staff, Leny Gamboa, whose signature on this form confirms receipt of the report.

SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran JainTELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
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