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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202612
Report Date: 11/21/2024
Date Signed: 11/21/2024 11:15:52 AM

Document Has Been Signed on 11/21/2024 11:15 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MERTZ CARE HOME IIFACILITY NUMBER:
435202612
ADMINISTRATOR/
DIRECTOR:		MERTZ, ELVIRAFACILITY TYPE:
735
ADDRESS:2722 MCLAUGHLIN AVETELEPHONE:
(408) 225-9094
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Staff Corazon GrimaresTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff S1, Corazon Grimares. During the visit, LPA observed 0 residents and 1 staff. LPA explained the purpose of the visit. LPA contacted ADM via phone call. ADM stated she was unavailable due to a scheduled event and staff S1 would sign on her behalf.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected.

While touring the backyard of the facility, LPA observed the wooden fence door, next to the patio directly adjacent to the dinning room. LPA observed a screw being used to stop the door from opening and closing due to the wind. ADM stated she will buy a new latch for the gate, and send LPA photo documentation showing the new latch has been installed. LPA explained to ADM that side of facility, adjacent to the dinning room is an emergency exit pathway, that must be accessible and not obstructed for the health and safety of the residents. ADM agreed and understood.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 73 degrees F, and hot water temperature was measured at 116 degrees F in the hallway bathroom. .


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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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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: MERTZ CARE HOME II
FACILITY NUMBER: 435202612
VISIT DATE: 11/21/2024
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Fire extinguisher was serviced in January 26, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on September 10, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA interviewed 1 staff. Residents were attending day program during LPA's visit.

LPA requested a copy of the following documents:
1. LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. Qualifications of Administrator (Certificate)

No deficiencies cited during today's visit. This report was reviewed with Staff S1, Corazon Grimares and a copy of the signed report was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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