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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202651
Report Date: 03/05/2024
Date Signed: 03/05/2024 04:02:42 PM

Document Has Been Signed on 03/05/2024 04:02 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 IVFACILITY NUMBER:
435202651
ADMINISTRATOR:EMMANUEL G FERNANDOFACILITY TYPE:
735
ADDRESS:1502 CONSTANSO WAYTELEPHONE:
(408) 882-3908
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 3CENSUS: 3DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Turino Malig, house managerTIME COMPLETED:
11:59 AM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manger (HM) Tyrino Malig.

LPA toured the facility inside and out with HM. 3 staff and 3 residents were observed in the facility.

LPA reviewed 3 resident files and 3 staff files.

Licensee, Administrator Certificate and personal right posters were observed in the facility. Living room, office, 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 73 degree F, and hot water temperature was at 110 degree F in facility. The temperature of the refrigerator was at 37 degree F, and the temperature of the freezer was at 0 degree F. Flash lights and first aid box were observed in the facility.

Fire extinguisher was serviced on 06/22/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by staff. The smoke detectors were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

The last time the facility conducted the emergency and fire drill is 2/5/2024.

Deficiencies were noted today. See LIC809-D. Exit interview was conducted with HM. This report was provided to HM for signature. A copy of the report was provided to HM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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 3
Document Has Been Signed on 03/05/2024 04:02 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 03/05/2024 at 11:20 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: MERIDIAN MANOR IV
FACILITY NUMBER: 435202651

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, licensee did not comply with the section cited above in that 1 out of 3 staff did not have health screening form, LIC503, which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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House manager stated the facility will submit a plan of correction by the POC due date and to have the staff to complete the LIC503.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that 1 out of 3 staff did not have a valid first aid certificate which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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House manager stated the facility will submit a plan of correction by the POC due date and to have the staff to complete the first aid training to obtain a first aid certificate.
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: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/05/2024 04:02 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 03/05/2024 at 11:20 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: MERIDIAN MANOR IV
FACILITY NUMBER: 435202651

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

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 3 out of 3 residents' centrally stored medication forms were not maintained accurate and up to date for March 2024 which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 03/05/2024
Plan of Correction
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House manager stated the facility will submit a plan of correction by the POC due date and to update the resident centrally stored medications forms as soon as possible, and to maintain them accurately and up to date.
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: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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