435202594-9-24-2025-26-AS-CKAI-DLU3DR-20250924180959

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202594
Report Date: 09/24/2025
Date Signed: 09/24/2025 06:10:14 PM

Document Has Been Signed on 09/24/2025 06:10 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:	COMMUNITY SOLUTIONS CRISIS RESIDENTIAL		FACILITY NUMBER:	435202594
ADMINISTRATOR/ DIRECTOR:	MATTHEW MIAO		FACILITY TYPE:	772
ADDRESS:	115 MADRONE AVENUE		TELEPHONE:	(669) 888-3182
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 15		CENSUS: 15	DATE:	09/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:30 PM
MET WITH:	Matthew Miao		TIME VISIT/ INSPECTION COMPLETED:	06:15 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) Christine Kabariti arrived unannounced to conduct the facility's required 1 - year annual inspection. LPA met with Administrator, Matthew Miao. LPA toured the facility with designated ADM to include the office rooms, hallways, living room, medication room, kitchen, dining room, laundry room, resident bedrooms, bathrooms, and exterior. All fire exit routes are free and clear of obstruction. During visit, at least 3 staff members were observed on duty. Facility's temperature maintained at 71 degrees F. Smoke detectors and carbon monoxide detectors are dual and observed present. Fire extinguisher last serviced on 02/21/2025. Fireplace observed screened and blocked in the living room area. Kitchen supplied with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Chemicals, disinfectants, and sharp objects observed locked. Refrigerator temperature maintained at 35 degrees F and freezer temperature maintained at 0 degrees F. Laundry room that contained chemicals, disinfectants, and sharp objects observed locked. LPA observed as basket full of bread (about 5 plastic packages of bread) stored inside the laundry room which supplies laundry appliances, laundry detergents, chemicals and disinfectants. The smell of the laundry detergents/chemicals was very strong. LPA observed the breads were best by 09/21/2025. LPA did not observe any mold on the bread. PAGE 1 OF 3.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025

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: COMMUNITY SOLUTIONS CRISIS RESIDENTIAL	FACILITY NUMBER: 435202594
	VISIT DATE: 09/24/2025

NARRATIVE

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Staff stated that the breads are not being used for the clients and are intended to be thrown out. In the laundry room cabinets, there are also food supplies to include can foods, cereals in storage containers, boxed cake mix, open flour, seasonings, and packaged snacks. LPA recommended to move the food supply from the laundry room and possibly store these items in a separate area as the smell of the laundry detergent/chemicals is very strong. Administrator stated understanding and states to possibly come up with a plan to relocate the food supply in another location.

Resident bedrooms observed with beds, linens, closet space, and adequate lighting. Bathroom hot water temperature maintained at 111.5 degrees F. Bathrooms observed with non-slid floors and grab bars.

Garage supplied with additional non-perishable food supplies. Freezer temperatures maintained at 0 degrees F.

2 out of 2 storage units to the right of the garage observed to contain storage items.

Medication room observed lock. Facility has a complete first aid kit. Sharp containers and PPE supplies observed. LPA reviewed 5 resident's centrally stored medications and centrally stored medication records. 5 out of 5 resident medications are completed and accounted for.

5 client records were reviewed to include an admissions agreement, consent forms, medical assessment, TB result, safeguard of personal properties, emergency contact information, and signed needs and services plan. 5 out of 5 resident's P&I money was inspected and observed complete.

4 staff files were reviewed. The 4 staff are fingerprint cleared and associated to the facility. LPA observed the staff files contains a job application, 1st Aid and CPR certification, and annual training records related to their job functions.

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NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025

LIC809 (FAS) - (06/04)

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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: COMMUNITY SOLUTIONS CRISIS RESIDENTIAL	FACILITY NUMBER: 435202594
	VISIT DATE: 09/24/2025

NARRATIVE

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The health screening and TB result was with the facility's HR's Department. During visit, 1 out of 4 staff members had a complete health screening and TB result. 3 out of 4 staff members health screenings were not on file. 1 out of 4 staff members did not file a TB result on file. A type B deficiency was cited today per Title 22 Section 81066(c)(10) wherein 3 staff members did not have a health screening on file and 1 out of 3 staff members did not have a TB result on file.

Facility has an emergency disaster plan. LPA advised to review and update the emergency disaster plan annually to ensure accuracy of the plan as the disaster plan was last dated on 09/20/2023. Emergency drills are being conducted monthly and the last drills were completed in June, July, and August 2025.

During visit, it was observed that bedroom #1 contained 3 beds. LPA had a printout of the facility sketch and fire clearance, which did not indicate that the bedroom was to be used for 3 residents. LPA Kabariti reviewed the facility file on 09/16/2025, which did not show any licensing approval of the bedroom arrangement. Administrator was unable to show proof that the arrangement was approved by licensing. It was stated that the facility did make some arrangements to the rooms over the past few years. A type A deficiency was cited per Title 22 Section 81087(e)(1) wherein bedroom #1 was currently being occupied by 3 clients.

Documents were requested by Friday, 10/03/2025 to update the facility file to include: Bacteriological Analysis, lease agreement, LIC308, LIC610D, LIC500, and administrator certificate.

Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809-D. A civil penalty of $250 was assessed today due to a repeat violation within a 12 month period of Section 81066(c)(10). This report was reviewed with Administrator, Matthew Miao and a copy of the report and appeal rights was provided.
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NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2025 06:10 PM - It Cannot Be Edited

Created By: Christine Kabariti On 09/24/2025 at 05:01 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: COMMUNITY SOLUTIONS CRISIS RESIDENTIAL	FACILITY NUMBER: 435202594
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

81087(e)(1)

(e) Bedrooms must meet, at a minimum, the following requirements: (1) No more than two clients shall sleep in a bedroom unless the program justifies a group living arrangement of more than two persons to a room and such arrangement is approved in writing by the licensing agency. 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 wherein it was observed that there are 3 clients in room #1 which was not approved prior from licensing which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2025
	Plan of Correction
1 2 3 4	Administrator states he will come up with a plan to ensure compliance with the section cited above. Administrator will submit a written plan to LPA Kabariti via email by POC due date of 09/25/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:

	Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 09/24/2025 06:10 PM - It Cannot Be Edited

Created By: Christine Kabariti On 09/24/2025 at 05:49 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: COMMUNITY SOLUTIONS CRISIS RESIDENTIAL	FACILITY NUMBER: 435202594
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81066(c)(10)

(c) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 81065(g). 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 wherein 3 staff members did not have a health screening on file and 1 out of the 3 staff members did not have a TB result on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/01/2025
	Plan of Correction
1 2 3 4	Administrator states that he will come up with a plan to ensure that all staff health screenings are available at the facility rather than the HR Department. Administrator will submit a written plan to ensure that all staff has a health screening and TB result on file and health screenings are accessible when requested by authorized agencies to LPA Kabariti via email by POC due date of 10/01/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:

	Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025

LIC809 (FAS) - (06/04)

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