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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202617
Report Date: 03/08/2024
Date Signed: 03/08/2024 05:47:00 PM

Document Has Been Signed on 03/08/2024 05:47 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:MOUNT PLEASANT CARE HOMEFACILITY NUMBER:
435202617
ADMINISTRATOR:DUMANTAY, MADONNA O.FACILITY TYPE:
735
ADDRESS:3280 COLDWATERDRTELEPHONE:
(408) 238-1662
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator Madonna DumantyTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Madonna Dumantay. During the visit, LPA observed 4 residents and 3 staff.

LPA toured the facility inside out with ADM 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. There was no obstruction to block the walkways.

While touring resident bedrooms, LPA observed staff bedroom (located between room 3 and receiving room), sliding screen door is damaged on the bottom left corner and that portion of screen is no longer attached to the frame. While touring facility master bedroom, LPA observed the window did not have a screen. LPA also observed the sliding screen door for the master bedroom did not have a sliding screen door. (Photographs were taken) While touring the facility family room, LPA observed the door between, the family room and the receiving room was damaged. LPA observed 4 indentations on the door. (Photographs were taken)

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 72 degrees F, and hot water temperature was measured at 117 degrees F in both resident bathrooms.

Fire extinguisher was serviced in April 18, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on March 2, 2024. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff (S1) and 1 residents (R1).
Deficiencies are being cited during today's visit, see LIC809-D. This report was reviewed with Administrator Madonna Dumanty and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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 03/08/2024 05:47 PM - It Cannot Be Edited


Created By: Manuel Monter On 03/08/2024 at 04:55 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: MOUNT PLEASANT CARE HOME
FACILITY NUMBER: 435202617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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. LPA observed master bedroom sliding door screen is missing and window is missing its screen. LPA observed the bedroom between bedroom 3 and receving room has a damaged slidding door screen. LPA observed the door between the family room and the receiving room was damaged. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure the facility shall be clean, safe, sanitary and in good repair at all times. ADM stated she will send the plan of action by POC date, March 15, 2024.
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 Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


LIC809 (FAS) - (06/04)
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