435202492-6-13-2025-26-AS-MYAZ-DHLPJY-20250613112219

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202492
Report Date: 06/13/2025
Date Signed: 06/13/2025 11:22:33 AM

Document Has Been Signed on 06/13/2025 11:22 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:	DYSICO CARE HOME, ARF		FACILITY NUMBER:	435202492
ADMINISTRATOR/ DIRECTOR:	MARIA BONUAN		FACILITY TYPE:	735
ADDRESS:	787 E. SAN CARLOS STREET		TELEPHONE:	(408) 286-5364
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY: 6		CENSUS: 6	DATE:	06/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Maria Bonuan Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:35 AM

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) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Maria Marquez, Administrator. LPA announced the purpose of the visit. LPA observed 1 staff and 1 resident. 4 out of 6 went to day program and 1 out of 6 is with family. During visit,LPA toured the facility inside and out. LPA toured the pantry and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, and cleaning supplies. LPA observed a unlocked cabinet with a knives accessible to residents in care. ADM removed knives and placed in locked drawer during visit. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. ADM tested the smoke detector in the hallway found the smoke detector to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 117 to 118 degrees F. Page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: DYSICO CARE HOME, ARF	FACILITY NUMBER: 435202492
	VISIT DATE: 06/13/2025

NARRATIVE

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LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 3/26/25. LPA reviewed Fire and Earthquake log the last fire drill was last conducted on 05/10/25, and earthquake on 04/21/25

LPA reviewed resident records 3 residents. LPA reviewed 2 staff records and centrally stored medication was reviewed by ADM and P & I was also reviewed by ADM.

Based on record review, 1 resident who is using full length bed rails does not contain a physician's order for full length bed rails. LPAs reviewed the facility file and the facility did not submit an exception request for the use of full length bed rails.

Deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Maria Marquez and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/13/2025 11:22 AM - It Cannot Be Edited

Created By: Marcela Yanez On 06/13/2025 at 11:04 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: DYSICO CARE HOME, ARF	FACILITY NUMBER: 435202492
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2025

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 and interview the licensee did not complywith the section cited above by having a tupperware with knives in an unclocked cabinet in kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/14/2025
	Plan of Correction
1 2 3 4	Administrator will submit a letter of understanding of regulation and will conduct inservice training and submit by poc due date 06/14/25 by email to LPA

Type A

Section Cited

CCR

80072(a)(8)(E)1

Personal Rights

1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in by having full bed rail for resident with no physicians order and did not submit for an exception which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/14/2025
	Plan of Correction
1 2 3 4	ADM will submit a letter of understanding of regulation and plan of action to obtain a doctors appointment for a Physicians order for full rails and request for an exception to the department by poc due date 06/14/25 by email to LPA

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Marcela Yanez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/13/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025

LIC809 (FAS) - (06/04)

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