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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202462
Report Date: 11/18/2023
Date Signed: 11/18/2023 12:18:28 PM

Document Has Been Signed on 11/18/2023 12:18 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:PEARSON'S CARE HOME #2FACILITY NUMBER:
435202462
ADMINISTRATOR:LOUELLA D. MANZANOFACILITY TYPE:
735
ADDRESS:4140 LOGANBERRY DRIVETELEPHONE:
(408) 300-1467
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
11/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Louella Manzano.TIME COMPLETED:
12:20 PM
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 Louella Manzano. During visit, LPA observed 2 residents and 2 staff.

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 4 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. 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 110 degrees F in both resident bathrooms.

While touring the backyard of the facility, LPA observed a black storage cabinet in driveway #2. LPA observed the cabinet was not locked and toxics were observed accessible to residents in care. (Photographs taken, and ADM observed.) LPA asked ADM if the residents have access to the backyard. ADM stated, yes, the residents can go to the backyard.

While interviewing R1, LPA observed a bottle of detergent in bedroom #1, in R3's side of the bedroom. ADM stated that detergent wasn't supposed to be there. (LPA took photograph)

Fire extinguisher was serviced in July 16, 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 conducted was on September 2022.

Page 1 out of 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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 4
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: PEARSON'S CARE HOME #2
FACILITY NUMBER: 435202462
VISIT DATE: 11/18/2023
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 ADM and S2 and 2 residents (R1-R2). All other residents left the facility for an outing.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Louella Manzano. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/18/2023 12:18 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/18/2023 at 11:55 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: PEARSON'S CARE HOME #2
FACILITY NUMBER: 435202462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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. While touring the backyard, LPA and ADM observed an unlocked black cabinete which contained toxics. LPA observed laundry detergent in resident bedroom #1 acsessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2023
Plan of Correction
1
2
3
4
ADM stated she will send a plan of action on how she will keep toxics/ cleaning solutions inaccessible to residents in care. ADM stated she will send plant to LPA by POC date, 11/19/2023.
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: 11/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/18/2023 12:18 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/18/2023 at 11:55 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: PEARSON'S CARE HOME #2
FACILITY NUMBER: 435202462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. A review of the facility's fire/earthquake drill log, the last drill conducted was on September 2022. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2023
Plan of Correction
1
2
3
4
ADM stated she will send a plan of action on how the facility will conduct drills at least quartlery and will send LPA documentaion that a drill has been conducted by POC date, 11/25/2023.
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: 11/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4