<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202650
Report Date: 03/06/2024
Date Signed: 03/06/2024 03:23:54 PM

Document Has Been Signed on 03/06/2024 03:23 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MERIDIAN MANOR VFACILITY NUMBER:
435202650
ADMINISTRATOR:EMMANUEL G FERNANDOFACILITY TYPE:
735
ADDRESS:15134 CHARMERAN AVETELEPHONE:
(408) 429-8323
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 3CENSUS: 3DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:EMMANUEL G FERNANDOTIME COMPLETED:
03:08 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) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) EMMANUEL G FERNANDO.

LPA toured the facility inside and out with ADM. 3 residents went to day program. 2 staff were observed in the facility.

LPA reviewed 2 resident files and 2 staff files.

License, administrator certificate and personal rights posters were observed in the facility. Living room, family room, kitchen, dinning room and two restrooms were inspected. Three single resident bedrooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 71 degree F, and hot water temperature was at 110 degree F in facility. The temperature of the refrigerator was at 35 degree F, and the temperature of the freezer was at 0 degree F.

Fire extinguisher was serviced on 06/01/2023. The facility was equipped with fire alarm system, and smoke and carbon monoxide detectors. ADM tested the smoke detector system and they were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. Emergency light system, flash lights and first aid box were observed in the facility. There was no night light in the hallway.

The last time the facility conducted the emergency and fire drill was on 2/9/2024.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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 2
Document Has Been Signed on 03/06/2024 03:23 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 03/06/2024 at 02:12 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: MERIDIAN MANOR V
FACILITY NUMBER: 435202650

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 that no night light was observed in the hallway which poses/posed a potential safety risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
1
2
3
4
Administrator stated he/she will submit a plan of correction by the POC due date to install night lights in the hallway.
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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2