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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202417
Report Date: 03/06/2025
Date Signed: 03/06/2025 10:17:30 AM

Document Has Been Signed on 03/06/2025 10:17 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:BAYMILL CARE HOMEFACILITY NUMBER:
435202417
ADMINISTRATOR/
DIRECTOR:		ZACARIAS, REMEDIOSFACILITY TYPE:
735
ADDRESS:2822 BAYSMILL COURTTELEPHONE:
(408) 225-9672
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 3DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Administrator Remedios ZacariasTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Remedios Zacarias. During the visit, LPA observed 0 residents and 1 staff. LPA explained the purpose of the visit. Residents were attending day program during LPA's visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 4 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.

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 108 degrees F in both resident bathrooms.

Fire extinguisher was serviced in October 11, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by Staff S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 2, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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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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: BAYMILL CARE HOME
FACILITY NUMBER: 435202417
VISIT DATE: 03/06/2025
NARRATIVE
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LPA reviewed 3 resident P&I records. Resident R1 P&I was counted by the administrator, which totaled to $743 dollars. ADM showed LPA 2 P&I records for R1. One record had R1's P&I balance as $80.62, while the other record had his/her balance at $942.53. ADM stated due to her husband being sick, they have not been able to update the P&I records. ADM stated she has not updated the expense records for R1 for the month of January - February 2025. ADM stated she made an additional record for each resident to make it easier to track.

Resident R2 also has 2 P&I records. One record stating his/her balance of $4,449.38 and another record stating he/she has a balance of $155.32. ADM stated there also expenses for R2 that have not been updated in R2's P&I records.

Resident R3's P&I cash was counted by ADM, which totaled, $6347.46. ADM stated R3 also has expenses from February 2025, which have not been accounted for, such as cloths. (Copies of all residents P&I records were obtained.)

A Deficiency is being cited during today's visit. This report was reviewed with Administrator Remedios Zacarias and a copy of the signed report was provided. Appeal rights were provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 10:17 AM - It Cannot Be Edited


Created By: Manuel Monter On 03/06/2025 at 10:07 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: BAYMILL CARE HOME
FACILITY NUMBER: 435202417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Based on a review of 3 Out of 3 resident P&I records, all 3 residents P&I records did not match the with the amounted that was counted for each resident. ADM stated she has not updated residents expenses for the month of January and February. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure residents cash resources records are accurate. ADM stated she will send the Plan of Action to LPA by POC date, March 13, 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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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