435202645-2-27-2025-26-AS-MPAA-DEAU5F-20250227141641

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202645
Report Date: 02/27/2025
Date Signed: 02/27/2025 02:17:21 PM

Document Has Been Signed on 02/27/2025 02:17 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:	SLEEPY HOLLOW CARE HOME		FACILITY NUMBER:	435202645
ADMINISTRATOR/ DIRECTOR:	DEGUZMAN, JOHANN		FACILITY TYPE:	735
ADDRESS:	2491 SLEEPY HOLLOW LN		TELEPHONE:	(408) 644-9278
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY: 6		CENSUS: 4	DATE:	02/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Teofila De Guzman and Maryann Tandas Staff		TIME VISIT/ INSPECTION COMPLETED:	01:45 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) Maria (Mita) Partoza a conducted an unannounced required 1 year inspection visit and met with staff (S1) Maryann Tandas and designated administrator (S2) Teofila De Guzman. Licensee/Administrator (LIC/ADM) Johann De Guzman was not present during the visit due to prior commitment and authorized S1 and S2 to sign for the reports. The facility is licensed to serve adults who have developmental disability ages 18 to 59. 4 are ambulatory and 2 may be non-ambulatory. LPA observed no resident present at the facility during the time of the visit 2 staff were present. LPA toured the facility inside and outside with staff including but not limited to the kitchen, bathroom, dining room, living room, 3 residents rooms, garage, backyard and exterior walkways. The temperature inside the home was at 68 degrees Fahrenheit. Resident Bedroom #2 for non-ambulatory residents has an emergency exit door with a dead-bolt can only be opened with a key. The alarm system on the door is not functioning. Staff (S1) stated that resident 1 (R1) have a running away/wandering behavior when R1 first moved in to the facility, hence the dead-bolt was placed. LPA discussed with S1 the importance of easy access to the exit doors in case of emergency. LPA discussed with S1 door alarm system based on the requirement for residents who are running away or wandering. The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. Under the sink cabinet is used to store chemicals and kept locked and not accessible to residents. The kitchen and bathroom water temperature measured at 107.9 to 111.9 degrees Fahrenheit. The bathroom/s are equipped with grab bars, non-skid mats. page 1 of 2 - see LIC 809C

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

Document Has Been Signed on 02/27/2025 02:17 PM - It Cannot Be Edited

Created By: Maria Partoza On 02/27/2025 at 12:58 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: SLEEPY HOLLOW CARE HOME	FACILITY NUMBER: 435202645
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80077.3(a)

Care for Clients who Lack Hazard Awareness or Impluse Control

(a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in by not replacing, repairing the auditory device on the door of bedroom #2 to alert staff. Instead LIC/ADM installed a dead-bolt lock in resident's bedroom #2 to prevent R1 from running away/wandering, which pose/poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	S1 was able to speak with LIC/ADM. LIC/ADM stated that the deadbolt lock will be replaced with a newer lock that can be easily accessed by staff in case of an emergency and an alarm system will be placed on the door to alert staff. POC will be submitted to LPA by LIC/ADM by the due date. LIC/ADM, S1 and S2 agreed and understood.

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.

SUPERVISOR'S NAME:

Romeo Manzano

LICENSING EVALUATOR NAME:

Maria Partoza

LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: SLEEPY HOLLOW CARE HOME	FACILITY NUMBER: 435202645
	VISIT DATE: 02/27/2025

NARRATIVE

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LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete.

The backyard, walkways, ramps and patio are free from debris and obstruction. The facility screen windows were observed to be in good repair. The washer and dryer are in good working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care.

The facility is equipped with a fire, smoke and carbon monoxide alert system were tested, hallway are free from obstruction and hallway lights were observed to be in good working condition.

LPA reviewed 4 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed records to be complete and updated.

LPA reviewed 3 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. The facility's fire and earthquake drill training was administered to staff on 11/22/2024. Fire extinguisher was last inspected on 11/13/2024.

A citation is issued during today's visit based on observation per the California Code of Regulations (CCR) Title 22 80077.3(a). An exit interview was conducted with designated administrator Teofila De Guzman (S2) and staff Mary Ann Tandas (S1). A copy of the report and appeals right was provided.

page 2 of 2
end of report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3