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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202567
Report Date: 11/10/2022
Date Signed: 11/10/2022 04:11:44 PM

Document Has Been Signed on 11/10/2022 04:11 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:SUCCESS RCF 1FACILITY NUMBER:
435202567
ADMINISTRATOR:AMAS, PRINCE-STANLEYFACILITY TYPE:
735
ADDRESS:64/68 SOUTH 10TH STREETTELEPHONE:
(408) 293-8166
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 32CENSUS: 32DATE:
11/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Prince-Stanley AmasTIME COMPLETED:
04:30 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) David Marrufo conducted an unannounced Case Management visit and met with Administrator Prince-Stanley Amas. The purpose of the visit was to issue citations for deficiencies that were found to have occurred during a complaint investigation but were not included as part of the original allegations.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Administrator Prince-Stanley Amas and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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 3
Document Has Been Signed on 11/10/2022 04:11 PM - It Cannot Be Edited


Created By: David Marrufo On 11/10/2022 at 01:49 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: SUCCESS RCF 1
FACILITY NUMBER: 435202567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/11/2022
Section Cited
CCR
80064(a)(3)

1
2
3
4
5
6
7
80064 (a)(3) Administrator qualifications
(a) The administrator shall have the following qualifications:
(3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by: Administrator did not show he has
1
2
3
4
5
6
7
Licensee agrees to develop a plan to have the Administrator take courses on personal rights, communication skills, and anger management and also consider taking a leave of absence and appointing another administrator. Licensee agrees to
8
9
10
11
12
13
14
knowledge and ability to comply with Title 22 as demonstrated in the way he handled R1 and R1’s personal belonging which poses an immediate threat to the health and safety of the resident in care.
8
9
10
11
12
13
14
submit the plan by POC date. Licensee agrees to submit copies of course completion certifications to CCL once they are complete.
Request Denied
Type A
11/11/2022
Section Cited
CCR80012(a)

1
2
3
4
5
6
7
80012(a) False Claims (a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Based on interview and
1
2
3
4
5
6
7
The Licensee agrees to train all staff on providing factual and complete information to Department representatives and submit plan to CCL by POC date.
8
9
10
11
12
13
14
record review, administrator denied any such incident happened when resident and police report collaborated on the incident which poses an immediate threat to the health and safety of the resident in care.
8
9
10
11
12
13
14
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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/10/2022 04:11 PM - It Cannot Be Edited


Created By: David Marrufo On 11/10/2022 at 01:51 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: SUCCESS RCF 1
FACILITY NUMBER: 435202567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/17/2022
Section Cited
CCR
80061(b)(1)(D)

1
2
3
4
5
6
7
80061(b)(1)(D) Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours.
1
2
3
4
5
6
7
The Licensee agrees to train staff on reporting requirements and submit proof of training along with names of staff, dates of staff trained and names and qualifications of trainers to CCL by POC date.
8
9
10
11
12
13
14
In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following:
(D) Any injury to any client which requires medical treatment. This requirement was not met as evidenced by: Based on interview, R1 required medical treatment and the department did not receive an incident report on this altercation which poses a potential threat to the health and safety of the resident in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3