435202656-11-10-2025-26-AS-MPAA-DNB2PC-20251110163407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202656
Report Date: 11/10/2025
Date Signed: 11/10/2025 04:34:25 PM

Document Has Been Signed on 11/10/2025 04:34 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:	MOUNT BLUE RESIDENTIAL CARE HOME INC		FACILITY NUMBER:	435202656
ADMINISTRATOR/ DIRECTOR:	FREDRICKA SAFAR		FACILITY TYPE:	735
ADDRESS:	1233 BRYAN AVE		TELEPHONE:	(415) 385-8900
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY: 6		CENSUS:	DATE:	11/10/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:45 PM
MET WITH:	Fredricka Safar		TIME VISIT/ INSPECTION COMPLETED:	05:00 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) Maria (Mita) Partoza, conducted a unannounced case management - incident report that was received by the Department on 11/10/2025. LPA met with Licensee/Administrator Fredricka Safar and stated the purpose of the visit. On 11/10/2025, the Department received an incident report alleging that a staff (S1) was witnessed by another staff (S2) standing over the resident and his/her face was very close to the resident. Based on the information received, S2 made a noise and S1 left the resident's room. ADM stated that he/she has not reported the incident to Law Enforcement but have reported the incident to the Adult Protective Services (APS). ADM stated that S1 is no longer associated with the facility. ADM will update the information on Guardian. LPA requested the following documents such as staff file record, resident's physician's report and appraisal needs and services. LPA Partoza, observed 5 Out of 6 residents were present at the facility. 1 Out of 6 was not at the facility and will arrive later in the afternoon, 2 Out of 6 was at the living room listening to music and supervised by staff. 1 Out of 6 was at the dining room area. 1 Out of 6 was in his/her bedroom asleep. page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: MOUNT BLUE RESIDENTIAL CARE HOME INC	FACILITY NUMBER: 435202656
	VISIT DATE: 11/10/2025

NARRATIVE

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LP toured the facility inside and outside observed no obstruction on the walkways and hallways. the Facility has 2.5 bath. 1 Out of two is located inside a resident bedroom and 1 Out of 2 is by the hallway. LPA inspected 3 out of 3 resident bedroom and observed 3 out 3 have sufficient storage to store resident's personal belongings. LPA observed a fenced in pool with lock on the gate.

LP observed that the exit door by the living room was locked, sliding door by the living room has plastic bubbles, HM stated that it was to prevent one of the clients for breaking the glass with his/her fist or head. The living door side door has a locking mechanism that would require a staff to unlock before it can be opened. LPA observed that R1s and R2s room have a sliding door leading to the backyard with the pool.

LPA observed that R1 and R2 are shares a room, R1 likes to sing and R2 is quietly sitting next to R1. R3 was at the corner and was eating his/her dinner, while R4 was seated on the other living room area next to the hallway near the resident's bedrooms.

LPA provided technical advisory to ADM to remove the mechanism that holds the door close/locked, addressed the screen doors on the sliding door and the hallway toilet clog.

It has been determined that the case management requires further investigation. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with licensee/administrator Fredricka Safar and a copy of the report was provided.

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end of report

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025

LIC809 (FAS) - (06/04)

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