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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202645
Report Date: 07/24/2026
Date Signed: 07/27/2026 01:08:16 PM

Document Has Been Signed on 07/27/2026 01:08 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 HOMEFACILITY NUMBER:
435202645
ADMINISTRATOR/
DIRECTOR:		DEGUZMAN, JOHANNFACILITY TYPE:
735
ADDRESS:2491 SLEEPY HOLLOW LNTELEPHONE:
(408) 644-9278
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6CENSUS: 4DATE:
07/24/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Johann De GuzmanTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Case Management-Incident visit on 07/24/2026 regarding reported incidents involving Resident 1 (R1). LPA met with two staff. No residents were present at the facility at the time of the visit. Administrator/Licensee (ADM/LIC) Johann De Guzman arrived at the facility but left at 9:15 a.m. due to a prior commitment.

On 05/06/2026, the Department received an incident report regarding Staff 1 (S1) and Staff 2 (S2). The incident report documented that 4 facility staff witnessed S1 and S2 physically harm R1 on multiple occasions. The reported incidents occurred on 04/26/2026, 04/27/2026, 04/28/2026, and 04/30/2026.

On 05/07/2026, LPA conducted an unannounced Case Management-Incident visit and interviewed Staff 3 (S3), Staff 4 (S4), and Staff 5 (S5). Staff 6 (S6) was not present at the facility during the visit. LPA also obtained staff declarations of S3, S4, S5, and S6, incident reports, SOC 341 reports, and the facility’s employee roster.

During the visit on 07/24/2026, LPA asked ADM/LIC when facility staff reported the incidents. ADM/LIC stated that staff reported the incidents to ADM/LIC on either 04/29/26 or 04/30/26 and that the facility submitted the incident report to Community Care Licensing Division (CCLD) on 05/06/2026.

The incident report documented incidents involving S1 on 04/27/2026 and 04/28/2026. S3, S4 and S6 declarations documented that on 04/27/2026, S1 struck R1’s arm with a slipper and slapped R1’s face with a sandal and further stated that on 04/28/2026, S1 slapped R1’s face and kicked R1's stomach.
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Romeo Manzano
Maria Partoza
DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2026
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: SLEEPY HOLLOW CARE HOME
FACILITY NUMBER: 435202645
VISIT DATE: 07/24/2026
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S5 stated that he/she was not present at the facility on 04/27/2026 or 04/28/2026 and did not witness the incidents reported on those dates by S3, S4 and S6. However, S5 stated that he/she witnessed S2 slap R1’s right cheek and kick R1 in the stomach on 04/26/2026 and again on 04/30/2026.

LPA asked whether R1 received a medical evaluation following the reported physical abuse. ADM/LIC stated that staff conducted a body check and did not observe bruising on R1. The incident report documented that on 05/02/2026, ADM/LIC did not observe visible marks or injuries on R1. However, when ADM/LIC asked whether R1’s stomach hurt, R1 responded, “Tummy hurts.” Records reviewed documented that R1 did not receive a medical evaluation following the reported incidents.

California Code of Regulations, Title 22, Section 80072(a)(3), Personal Rights, states: (a)"Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.”

Based on interviews and records reviewed, staff witnessed S1 and S2 slap, strike, and kick R1 on multiple occasions. The facility did not ensure that R1 was free from corporal punishment and infliction of pain. Therefore, a deficiency is cited pursuant to California Code of Regulations, Title 22, Section 80072(a)(3).

California Code of Regulations, Title 22, Section 80061(b)(1)(F), Reporting Requirements, states:
“Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency’s next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (F) Any suspected physical or psychological abuse of any client.”

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
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: SLEEPY HOLLOW CARE HOME
FACILITY NUMBER: 435202645
VISIT DATE: 07/24/2026
NARRATIVE
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Based on interviews and records reviewed, ADM/LIC was notified of the reported physical abuse on 04/29/2026. The Department received the facility’s written incident report on 05/06/2026. The facility did not report the suspected physical abuse to the licensing agency within the agency’s next working day. Therefore, a deficiency is cited pursuant to California Code of Regulations, Title 22, Section 80061(b)(1)(F).

California Code of Regulations, Title 22, Section 80075(a), Health-Related Services, states: “The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.”

Based on interviews and records reviewed, R1 was reportedly slapped, struck, and kicked on multiple occasions. On 05/02/2026, R1 reported that R1’s stomach hurt. The facility conducted a body check but did not arrange for R1 to receive a medical evaluation following the reported physical abuse and complaint of stomach pain. Therefore, a deficiency is cited pursuant to California Code of Regulations, Title 22, Section 80075(a).

Deficiencies were cited during today’s visit pursuant to California Code of Regulations, Title 22, Sections 80061(b)(1)(F), 80072(a)(3), and 80075(a). See LIC 809-D for additional information.

ADM/LIC Johann De Guzman authorized Zenaida Villanueva to sign and receive this report on her behalf. An exit interview was conducted with staff Zenaida Villanueva and a copy of the report and appeals rights were provided.

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end of report
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/27/2026 01:08 PM - It Cannot Be Edited


Created By: Maria Partoza On 07/24/2026 at 12:30 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: 07/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2026
Section Cited
CCR
80061(b)(1)(F)

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80061 Reporting Requirements...(b)
“Upon the occurrence.. of any of the events specified...next business working day (1) Events reported shall include the following: (F) Any suspected physical or psychological abuse of any client. This requirement was not met as evidenced by:
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Staff stated that he/she will notify ADM/LIC that ADM/LIC will need to submit a written plan of correction to address timely reporting per CCR 80061(b)(1)(F) and notify that the written plan of correction is required by the due date of 07/30/2026.
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Based record review and interview, the facility did not timely report the suspected physical abuse to CCLD when staff reported on 4/30/26 that R1 was kicked on the stomach by S2, which pose/s a potential health, safety and personal right risk to persons 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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/27/2026 01:08 PM - It Cannot Be Edited


Created By: Maria Partoza On 07/24/2026 at 12:08 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: SLEEPY HOLLOW CARE HOME
FACILITY NUMBER: 435202645

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2026
Section Cited
CCR
80072(a)(3)

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 80072 Personal Rights (a)..each client shall have personal rights which include... (3) To be free from corporal or unusual punishment, infliction of pain... This requirement is not met as evidenced by:
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Staff stated that he/she will submit notify ADM/LIC that a written plan of correction is rquired to ensure that residents in are are free from corporal punishments, infliction pain as stated on the regulation of 80072(a)(3) and notify ADM to submit the plan of correction by the due date of 07/25/26.
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Based on record review and interviews, the facility did not ensure that R1 was free from corporal or unusual punishment and infliction of pain when S1 & S2 physically abused R1 as witnessed by 4 staff (S3, S4, S5 & S6) on 4/26/26 to 4/30/26, which pose/s an immediate health, safety and personal rights
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 con't risk to persons in care.
Type A
07/24/2026
Section Cited
CCR80075(a)

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80075 Health-Related Services (a)The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement is not met as evidenced by:
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Staff stated that he/she will submit notify ADM/LIC that a written plan of correction is rquired to ensure that residents are medically evaluated based on 80075 (a) and will notify ADM tol submit the plan of correction by the due date of 07/25/26.
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Based on record review and interview on 4/30/26, R1 was reportedly kicked in the stomach, later stated “Tummy hurts,” & was not medically evaluated. The lack of medical assessment following abdominal trauma which pose/s an immediate health, safety and personal rights risk to persons 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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2026


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