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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202649
Report Date: 12/18/2024
Date Signed: 12/18/2024 04:49:32 PM

Document Has Been Signed on 12/18/2024 04:49 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:SVS SAN JOSE INCLUSION CENTERFACILITY NUMBER:
435202649
ADMINISTRATOR/
DIRECTOR:		PERKINS, CYNTHIAFACILITY TYPE:
775
ADDRESS:1304 SARATOGA AVETELEPHONE:
(408) 861-4993
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 60CENSUS: 24DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Nai SaechaoTIME VISIT/
INSPECTION COMPLETED:
12:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Program Director (PD) Nai Saechao.

LPA reviewed 3 clients files and 3 staff files. 9 clients went out for activity with 3 staff, and 6 clients in the facility with 6 staff. LPA toured the whole facility with PD. License and personal rights posters were observed in the facility.

Front desk, offices, conference room, computer room, visitor room, activity rooms, restrooms, kitchens, game room, storages rooms, quiet room, and exercise room were observed and inspected in the facility. Dish washing solution was observed unlocked on the top of the sink in the kitchen. PD put the dish washing solution in the cabinet under the sink immediately, but still accessible to clients. PD stated the facility will lock the cabinet under the sink by tomorrow.

Room temperature was 72 degree F. The facility was equipped with smoke and carbon monoxide detectors. Smoke detector alarm system was tested, and was working fine. Fire extinguisher was serviced on 7/1/2024.
Hot water temperature was observed at 106 degree F. First aid box, flash lights were observed in the facility. The last time the facility conducted the emergency drill was on 10/18/2024.

Based on the review of the fire inspection report issued by the fire department on 9/17/2024, there is no violation or deficiency noted in the facility.

Front yard and backyard were inspected. There was no obstruction to block the walkways.

Deficiency noted today. See LIC809-D. Exit interview was conducted with PD, This report was provided to PD for signature. A copy of the reports was provided to PD.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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 12/18/2024 04:49 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 12/18/2024 at 11:48 AM
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: SVS SAN JOSE INCLUSION CENTER
FACILITY NUMBER: 435202649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that dish washing solution bottle was observed on the top of the sink in the kitchen accessible to clients which poses an immediate 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 dish washing solution inaccessible to clients and to submit the evidence of fixing to LPA.
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: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
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