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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202650
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:17:43 PM

Document Has Been Signed on 03/11/2025 04:17 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:MERIDIAN MANOR VFACILITY NUMBER:
435202650
ADMINISTRATOR/
DIRECTOR:		EMMANUEL G FERNANDOFACILITY TYPE:
735
ADDRESS:15134 CHARMERAN AVETELEPHONE:
(408) 429-8323
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 3CENSUS: 3DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:EMMANUEL G FERNANDOTIME VISIT/
INSPECTION COMPLETED:
12:07 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) EMMANUEL FERNANDO.

LPA toured the facility inside and out with ADM. 3 residents went to day program. 1 staff were observed in the facility.

LPA reviewed 2 resident files (R1, R2) and 2 staff files (S1, S2). The appraisal needs and service plan of resident R1 was found over 12 months. Staff S2 was found not associated with the facility. ADM showed the document that S2 was associated with the facility in 2022. ADM shows the document that S2 was associated with Meridian Manor II.

License, and personal rights posters were observed in the facility. ADM provided all the documents that he/she renew the Administrator Certificate. Living room, family room, kitchen, dinning room and two restrooms were inspected. Three single resident bedrooms, a office, 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 42 degree F, and the temperature of the freezer was at 0 degree F.

Fire extinguisher was serviced on 06/28/2024. The facility was equipped with fire alarm system, and smoke and carbon monoxide detectors. ADM tested the carbon monoxide detectors and they were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. One storage room was observed at the backyard. Emergency light system, flash lights, night lights and first aid box were observed in the facility.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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: MERIDIAN MANOR V
FACILITY NUMBER: 435202650
VISIT DATE: 03/11/2025
NARRATIVE
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The last time the facility conducted the emergency and fire drill was on 1/25/2025.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/11/2025 04:17 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 03/11/2025 at 12:20 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 1 out 2 staff (S2) was found not associated with the facility which poses/posed a potential health, safety risk to persons in care. ADM stated S2 was associated with the facility in year 2022. ADM stated S2 was associated Meridian Manor II.
POC Due Date: 03/18/2025
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due date to ensure S1 and all staff are associated with the facility.
Type B
Section Cited
HSC
1507(c)(1)(B)
General Provisions
(1) For regional center clients the following shall apply: (B) The client's individualized health care plan shall be reassessed at least every 12 months or more frequently as determined by the client's physician or nurse practitioner during the time the client receives incidental medical services in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that resident R1's appraisal needs and service plan was observed over 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Administrator stated to submit the plan of correction by the POC due date to ensure appraisal needs and service plans of all residents are done annually.
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: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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