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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202564
Report Date: 02/28/2024
Date Signed: 02/28/2024 08:57:15 PM


Document Has Been Signed on 02/28/2024 08:57 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:CHERISH SENIOR CARE HOMEFACILITY NUMBER:
435202564
ADMINISTRATOR:PANGALIMAN, LEILANIE TFACILITY TYPE:
740
ADDRESS:2858 ROSS AVENUETELEPHONE:
(408) 266-0507
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 4DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Leilanie PangalimanTIME COMPLETED:
04:34 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Leilanie Pangaliman.

LPAs reviewed 3 resident files and 3 staff files. 4 residents and 2 staff were observed in the facility. LPA toured the facility inside out with ADM. Facility license, Administrator Certificate, Personal Rights posters were observed posted at the facility. Living room, kitchen, dinning room and two restrooms were inspected. Six single resident bedrooms, and laundry room were inspected. Two staff live-in rooms are in facility. Non skid mats were observed in the bathrooms.

Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet were observed locked. Dish cleaning product was observed unlocked in the kitchen. Room temperature was at 69 degree F, and hot water temperature was at 119 degree F in facility. The temperature of the refrigerator was at 38 degree F, and the temperature of the freezer was at 0 degree F. First aid box and flash lights were observed in the facility. Door alarms were observed in the facility. LPA tested the door alarms and the facility signal system, and they were working fine.

Fire extinguisher was serviced on 02/20/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Fire alarm and smoke detectors were tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. The facility conducted the fire and emergency drill on 1/27/2024. ADM added a lock under the sink in the kitchen to put the dish cleaning products before LPA exited the facility.

Deficiencies were noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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Document Has Been Signed on 02/28/2024 08:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: CHERISH SENIOR CARE HOME
FACILITY NUMBER: 435202564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 in that the storage cabinet of dish soap under the sink in the kitchen was observed unlocked which poses/posed a potential safety risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Administrator stated the facility will submit a plan of correction by the POC due date. Administrator added a lock for the cabinet under the sink in the kitchen to place the dish soaps before LPA exited the facility.
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 ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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