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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202578
Report Date: 07/11/2024
Date Signed: 07/11/2024 04:20:49 PM

Document Has Been Signed on 07/11/2024 04:20 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:CEDAR MANOR LLCFACILITY NUMBER:
435202578
ADMINISTRATOR/
DIRECTOR:		CASIM, ELVIRAFACILITY TYPE:
735
ADDRESS:415 HEATH STREETTELEPHONE:
(408) 945-9197
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 6CENSUS: 5DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Ronaldo RapisuraTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Ronaldo Rapisura, Lead Care Giver.

During visit, LPA Marrufo toured the facility inside and out. The facility kitchen and food storage areas had a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA Marrufo observed locked storage areas for sharp objects and cleaning supplies. The first aid kit was inspected and found to be complete.

LPA toured 3 out of 3 resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA Marrufo tested 1 out of 1 carbon monoxide detector and each smoke detector in the hallway, living room and 3 bedrooms. All carbon monoxide and smoke detectors functioned properly when tested. LPA toured the outside area and found the exit to be clear of obstructions.

LPA toured 1 out of 1 facility restrooms and found the restroom had working lights and available soap and paper towels. The water temperature in the bathroom sink was 108 F.

LPA reviewed 5 out of 5 resident Personal and Incidental Money Logs and found them to be balanced. LPA Marrufo reviewed 2 out of 2 Centrally Stored Medication and Destruction Records (only 2 residents take medications) and found them to be complete. LPA Marrufo reviewed 5 out of 5 resident records and observed resident R1's record was missing a Physician's Report and resident R2's record was missing an Admission Agreement and a Physician's Report. LPA reviewed 4 staff records and observed staff S1 was missing a current First Aid certification and staff S2 and S3 were missing LIC9052 Employee Rights forms. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. An Advisory Note was issued. See LIC9102 form for more information. This report was reviewed with Ronaldo Rapisura and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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 07/11/2024 04:20 PM - It Cannot Be Edited


Created By: David Marrufo On 07/11/2024 at 03:43 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: CEDAR MANOR LLC
FACILITY NUMBER: 435202578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(6)
80070 Client Records (b) Each record must contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 80068.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 1 out of 5 reviewed resident records, as evidenced by 1 out of 5 resident records did not contain an Admission Agreement, which poses a potential personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Licensee agrees to submit a copy of resident R2's completed Admission Agreement to CCL by POC date.
Type B
Section Cited
CCR
80070(b)(8)
80070 Client Records (b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 out of 5 resident records, as evidenced by 2 out of 5 resident records did not contain a Physician's Report, which poses a potential personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Licensee agrees to submit a copy of the Physician's Reports for residents R1 and R2 to CCL by POC date
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: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/11/2024 04:20 PM - It Cannot Be Edited


Created By: David Marrufo On 07/11/2024 at 03:57 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: CEDAR MANOR LLC
FACILITY NUMBER: 435202578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
80075 Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 1 out of 4 personnel records, as evidenced by 1 out of 4 personnel records did not include a current first aid certification, which poses a potential safety risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Licensee agrees to submit a copy of staff S1's current first aid certification to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


LIC809 (FAS) - (06/04)
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