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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202462
Report Date: 10/17/2024
Date Signed: 10/17/2024 04:50:06 PM

Document Has Been Signed on 10/17/2024 04:50 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/
DIRECTOR:		LOUELLA D. MANZANOFACILITY TYPE:
735
ADDRESS:4140 LOGANBERRY DRIVETELEPHONE:
(408) 300-1467
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Administrator Louella Manzano.TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Louella Manzano. During the visit, LPA observed 2 residents and 2 staff. LPA explained the purpose of the visit.

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. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the bathroom directly next to bedroom #3 and #2, LPA opened the cabinet under the sink. LPA observed a purple bottle of floor cleaner. ADM stored the cleaning solution during visit. LPA also observed one container of dish detergent, blue, inside the medicine cabinet. A container of orange dish detergent was observed on the sink as well. (Photographs were taken.) ADM removed the chemicals during visit.

While touring the facility kitchen, LPA requested to see the knives storage area. ADM stated she locks the knives in her room. ADM also stated she hides one of the knives in a cabinet in the kitchen. LPA requested to see. LPA observed the cabinet which contained the knife as unlocked. LPA requested ADM to secure the knife in a secure location, inaccessible to residents in care. ADM locked the knife inside her room during LPA's visit.

While touring the backyard, LPA observed the fence directly next to bedroom #2 was leaning. ADM stated she is currently collaborating with the neighbor on fixing the fence. ADM stated they already have an estimate regarding the cost. LPA requested a copy of the facility's plan of action, on how they will ensure the fence is safe and in good repair.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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: PEARSON'S CARE HOME #2
FACILITY NUMBER: 435202462
VISIT DATE: 10/17/2024
NARRATIVE
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Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 77 degrees F, and hot water temperature was measured ranging from 112-116 degrees F in resident bathrooms.

Fire extinguisher was serviced in June 21, 2024. 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 was on August 12, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA requested to reviewed staff S1's employee file. While reviewing the file, only the first aid and training documents could be found. LPA requested to review S1's LIC501, LIC503, LIC508, LIC9052. ADM stated the facility did fill out the forms, but she cannot find them.

LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 2 residents. LPA reviewed 3 residents P&I records.

Deficiencies and a technical violation was cited during today's visit. This report was reviewed with Administrator Louella Manzano and a copy of the signed report was provided. Appeal rights were also provided.

Page 2 Out of 2. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2024 04:50 PM - It Cannot Be Edited


Created By: Manuel Monter On 10/17/2024 at 04:22 PM
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: 10/17/2024

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
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Based on observation, the licensee did not comply with the section cited above. LPA observed 2 containers of dish washing detergent and floor cleaner inside the bathroom directly next to bedroom #3 and #2, accessible to residents in care. LPA observed a kitchen cabinet which contained the knife as unlocked and acessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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ADM removed the chemicals and knife during visit. ADM stated she will send a written letter of understanding regarding the regulation, stating her understanding that Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to residents shall be stored where inaccessible to residents in care. ADM stated she will send the written plan of correction by POC date, October 18, 2024.
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: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2024 04:50 PM - It Cannot Be Edited


Created By: Manuel Monter On 10/17/2024 at 04:24 PM
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: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
80066 Personnel Records (c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. LPA requested to reviewed staff S1's employee file. While reviewing the file, only the first aid and training documents could be found. LPA requested to review S1's LIC501, LIC503, LIC508, LIC9052. ADM stated the facility did fill out the forms, but she cannot find them. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will provide LPA with a copy of the missing documents: LIC501, LIC503, LIC508, LIC9052. ADM stated she will send the plan of correction to LPA by POC date, October 24, 2024.
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: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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