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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202629
Report Date: 06/06/2023
Date Signed: 06/06/2023 01:10:33 PM


Document Has Been Signed on 06/06/2023 01:10 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:BLENDED FAMILY CARE HOMEFACILITY NUMBER:
435202629
ADMINISTRATOR:PAGKALINAWAN, MICHELLEFACILITY TYPE:
740
ADDRESS:10366 MILLER AVENUETELEPHONE:
(408) 802-6410
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:12CENSUS: 8DATE:
06/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Michelle PagkalinawanTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Simi Rai and conducted a case management visit to follow up on deficiencies observed during inspected for pre-licensing visit for Lotus of Cupertino Care Home on 6/1/2023. LPA met with Administrator (ADM) Michelle Pagkalinawan.

During today's visit, LPA conducted further investigation on deficiencies observed on 6/1/2023. LPA Rai observed the administrator and landlord working on projects throughout the facility. The following deficiencies were cleared during today's visit.

For regulation, CCR 87303(a), Administrator worked with landlord to replaced the exit door in question. LPA Rai observed the new door and was able to open the door and walk through.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

A civil penalty of $250 will be assessed for a repeat violation within 12 months of the initial citation. If the deficiency is not corrected within 24 hours, an additional $100 will be assessed until the deficiency is corrected. See LIC421FC.

This report was reviewed with Administrator Michelle Pagkalinawan and a copy of the report was provided. Appeal Rights was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
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 06/06/2023 01:10 PM - It Cannot Be Edited

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: BLENDED FAMILY CARE HOME
FACILITY NUMBER: 435202629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2023
Section Cited
CCR
87303(a)

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Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
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Administrator will work with landlord and replace the door by POC date.
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Based on observation, exit door in Room #1 do not close without exerted effort which the resident may not be able to open in an emergency which poses an immediate Health, Safety or Personel Rights risk to residents in care.
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Type B
06/09/2023
Section Cited
CCR87303(c)

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Maintenanct and Operation: All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
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Administrator work with the landlord will replace screen door and send a picture to the LPA by POC date.
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Based on observation, the window screen in bathroom attached to Room #8 was ripped and open approximately 1in X 3in gap on the bottom of the screen.
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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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/06/2023 01:10 PM - It Cannot Be Edited

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: BLENDED FAMILY CARE HOME
FACILITY NUMBER: 435202629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2023
Section Cited
CCR
87309(a)

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87309 (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
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Administrator removed the laundry detergent during visit. Administrator will provide training to staff and written plan on understanding the regulation and how the facility will continue to keep the resident's safe.
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Based on observation, facility did not lock up laundry detergeny in the laundry area which poses an immediate Health, Safety or Personel Rights risk to residents in care.
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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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
LIC809 (FAS) - (06/04)
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