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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202620
Report Date: 12/12/2024
Date Signed: 12/12/2024 04:59:23 PM

Document Has Been Signed on 12/12/2024 04:59 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:PARK SOMMERS HOUSEFACILITY NUMBER:
435202620
ADMINISTRATOR/
DIRECTOR:		CANLAS JR., AVELINO RFACILITY TYPE:
735
ADDRESS:4451 PARK SOMMERS WAYTELEPHONE:
(408) 823-7168
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 6DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:AVELINO R CANLASTIME VISIT/
INSPECTION COMPLETED:
04:39 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Avelino Canlas.

3 staff and 3 residents were observed in facility. LPA reviewed 3 staff files and 3 resident files.

License, Administrator Certificate, and personal rights posters were observed at the main entrance.

LPA toured the facility with ADM inside and out. LPA inspected living room, family room, dinning area, kitchen. There are 2 restrooms, 1 staff live-in room, 3 resident rooms in facility. Two days perishable foods and seven day non perishable foods were observed sufficient. The temperature of the refrigerator was observed at 36 degree F, and the temperature of the freezer was observed at 0 degree F. Room temperature was observed at 70 degree F, hot water temperature was observed at 110 degree F. Medication cabinet, knife closet were observed locked. Cleaning products closet was observed locked. The facility was equipped with smoke and carbon monoxide detectors. carbon monoxide detectors was tested, and was working fine. Fire extinguisher was service on 12/12/2024. First aid box, flash lights, and night lights were observed at the facility.

Front yard and backyard were inspected. There was no obstruction to block the walkways. Two storage rooms were observed at the backyard.

The last time the facility conducted the emergency frill was on 11/11/24.

Deficiency noted for today's visit. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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 12/12/2024 04:59 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 12/12/2024 at 04:08 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: PARK SOMMERS HOUSE
FACILITY NUMBER: 435202620

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 3 Out of 3 staff files were observed that Administrator only can provided partial of the staff continuous training log document which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due date to ensure the facility provides staff training and maintains complete staff training log documents.
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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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