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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202652
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:18:15 PM


Document Has Been Signed on 01/24/2024 03:18 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:COMPASSIONATE RESIDENTIAL CARE HOME INCFACILITY NUMBER:
435202652
ADMINISTRATOR:DEVANO, BELINDAFACILITY TYPE:
740
ADDRESS:2795 GEORGE BLAUER PLTELEPHONE:
(408) 238-8781
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:6CENSUS: 4DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Belinda DevanoTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mita Partoza conducted an unannounced annual required inspection to the facility. LPA met with administrator (ADM) Belinda Devano and 1 staff.

4 out of 4 residents are under hospice care.

During visit, LPA toured the facility to include the living room, dining room, kitchen, bedrooms, bathroom, garage, and backyard. Staff room was inspected, 2.5 bathroom were inspected. The bathroom hot water temperature was measured at 105F to 115F. The room temperature in the facility was at 68-75F.

LPA randomly reviewed resident and staff records including residents medications.
Perishable and non-perishable food supply are within required regulation. Toiletries such toilet paper, paper towels, toothpaste are inspected and found to be in ample supply. Toxic materials such as laundry detergent, disinfectant are inaccessible to residents (locked in a cabinet).

LPA tested the smoke/carbon monoxide and found to be in good working condition. Night lights are also observed and are in good working condition. All designated emergency exits and passage ways are clear from obstructions.

Staff and Administrator were interviewed and reminded about infection control plan. LPA reviewed training for emergency disaster was last administered on 7/4/2023.

A deficiency was cited per California Code of Regulations, Title 22 during today's visit. This report was reviewed with administrator Belinda Devano and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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 01/24/2024 03:18 PM - It Cannot Be Edited

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: COMPASSIONATE RESIDENTIAL CARE HOME INC
FACILITY NUMBER: 435202652

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Licensee stated
Type A
Section Cited
HSC
1569.9(c)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on recoed review], the licensee did not comply with the section cited above in 1 out of 1 identfier which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Licensee will conduct training as soon as possible and sent proof of training to LPA by 1/26/2024 before the end of the day at 5:00 p.m.
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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2