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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202553
Report Date: 01/24/2024
Date Signed: 01/25/2024 08:04:13 AM

Document Has Been Signed on 01/25/2024 08:04 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CAPITOL CARE HOMEFACILITY NUMBER:
435202553
ADMINISTRATOR:DEGUZMAN, JOHANNFACILITY TYPE:
735
ADDRESS:849 S CAPITOL AVENUETELEPHONE:
(408) 644-9278
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 6DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Johann DeguzmanTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with Administrator (ADM) Johann Deguzman (ADM).

LPA observed 2 staff (S1, S2) and 1 resident (R1) in the facility. LPA reviewed 3 resident files (R1 - R3) and 3 staff files (S1 - S3).

LPA toured the facility with S1 inside and out. License, personal rights posters, and Administrator Certificate were observed in the main entrance. Living room, dining room, garage and kitchen were inspected. 1 staff live-in room was observed in the facility. 3 resident bedrooms, 2 bathrooms were inspected. One of the bathroom did not have the non skid mat.

Two days perishable foods and seven day non perishable foods were observed sufficient. Room temperature was observed at 70 degree F, hot water temperature was observed at 113 degree F. Medication cabinet, Knife closet, and cleaning products closet were observed locked. Fire extinguisher was serviced on 11/09/2023. The facility was equipped with fire alarm system and carbon monoxide detectors. Fire alarm and smoke detector alarm system were tested, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

First aid box, flash lights were observed in the facility. ADM stated the facility conducted the emergency drill on 12/22/2023.

Deficiency was noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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
Document Has Been Signed on 01/25/2024 08:04 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 01/24/2024 at 12:41 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: CAPITOL CARE HOME
FACILITY NUMBER: 435202553

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above in that one of the two bathrooms did not have non-skid mats, which poses/posed a potential safety risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator stated the facility will submit a plan of correction by POC due date and to buy new non-skid mat and put in the bathroom.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 in that no night lights were observed in the facility, which poses/posed a potential safety risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator stated the facility will send a plan of correction by the POC due date to state understanding of the title 22 regulations, administrator put two night light on in the facility after LPA's inspection.
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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
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