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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202443
Report Date: 09/11/2024
Date Signed: 09/11/2024 11:27:11 AM

Document Has Been Signed on 09/11/2024 11:27 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:MLJ CARE HOMEFACILITY NUMBER:
435202443
ADMINISTRATOR/
DIRECTOR:		LOLITA R. BAUTISTAFACILITY TYPE:
735
ADDRESS:2882 SCOTTSDALE DRIVETELEPHONE:
(408) 238-2949
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
09/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:House Manager, Sheryll Granil TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez conducted a case management visit to assess resident R1 for total care exception request. LPAs met with House Manager (HM) Sheryll Granil and stated the purpose of today's visit. LPA Rai spoke with Licensee/Administrator Lolita Bautista, who was not present at the facility at the time of visit and LPA Rai stated the purpose of today's visit. Licensee/Administrator Lolita Bautisa gave verbal authorization for House Manager, Sheryll Granil to sign today's report on her behalf.

During today's visit, LPAs observed two staff, including HM and one resident (R1) present during today's visit. Five residents were attending day program and not present at the facility. LPAs interviewed two staff, HM and S1 and interview/observed resident R1. Resident R1 is dependent on staff to care and supervise R1's activity's of daily living (ADLs). However, R1 is able to communicate his/her needs by verbal communication which includes but not limited to responses of "yes", "no", "music", and "eat". R1 is able to identify and distinguish the different caregivers providing care and supervision by stating their name.

Based on interview and observation, total care exception is not needed at the time. The processing of the total care exception has ceased.

The facility staff shall continue to daily documentation of resident’s condition and care provided should be kept in her files. Any changes in resident’s condition should be reported immediately to her primary care physician, responsible party and licensing agency. Facility staff will monitor resident’s health care needs and collaborate with her primary physician regarding care. Facility staff shall ensure R1's Appraisal Needs and Services Plan is updated annually or as needed if the resident experiences significant physical or mental changes. Facility shall provide ongoing annual staff training specific to the needs of resident and shall be documented in facility records.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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: MLJ CARE HOME
FACILITY NUMBER: 435202443
VISIT DATE: 09/11/2024
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Licensee/Administrator shall notify the Department if there are any changes to R1 wherein R1 is not able to communication his/her needs and Licensee/Administrator can submit total care exception to retain resident at the facility at that time.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with House Manager, Sheryll Granil and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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