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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202672
Report Date: 07/23/2024
Date Signed: 07/23/2024 05:16:15 PM

Document Has Been Signed on 07/23/2024 05:16 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:MINAS ELDERLY CARE HOME 1FACILITY NUMBER:
435202672
ADMINISTRATOR/
DIRECTOR:		ABBASVAND, MINAFACILITY TYPE:
740
ADDRESS:112 GARDEN HILL DRIVETELEPHONE:
(408) 348-8361
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY: 6CENSUS: 6DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Mina AbbasvandTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Steve Chang and Marcela Yanez conducted an unannounced annual inspection visit, and met with Administrator (ADM) Mina Abbasvand .

LPA observed 6 residents and 2 staff in the facility. LPA reviewed 3 residents files and 3 staff files. LPA observed one staff S1 on LIC500, but is not associated with the facility. ADM showed documents with S1's criminal clearance and he/she sent the criminal background clearance transfer request on 5/13/2022. LPA explained ADM should confirm that the employee is associated with the facility, then start to work for the facility.

LPAs toured the facility inside and out and ADM. License, expired Administrator Certificate, and personal rights posters were observed in the facility. ADM showed the evidence that he/she renewed the Administrator certificate already.

LPAs toured the facility inside out with ADM. Living room, kitchen, dinning room and three restrooms six single resident bedrooms, and laundry area were inspected at the first floor. 4 staff live-in rooms and one bathroom were observed at the second floor. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet and knives closet were observed locked. Cleaning product room was observed locked. Dish washing soap closet under the sink was observed unlocked. ADM locked the Dish washing soap closet under the sink before LPA finished the inspection. Room temperature was at 75 degree F, and hot water temperature was at 107 degree F in facility. The temperature of the refrigerator was at 40 degree F.

ADM tested the call button system and call light system, and were working fine. First aid box and flash lights were observed at the facility. The last time the facility conducted the emergency drill is 6/8/2024.
Continue on LIC9099-C. Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MINAS ELDERLY CARE HOME 1
FACILITY NUMBER: 435202672
VISIT DATE: 07/23/2024
NARRATIVE
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Fire extinguisher was serviced on 4/19/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by staff, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. The detached garage was observed a storage room.

Deficiency was noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/23/2024 05:16 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 07/23/2024 at 01:06 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: MINAS ELDERLY CARE HOME 1
FACILITY NUMBER: 435202672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) 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 ADM submitted a criminal background clearance transfer request, but did not associate the staff S1 with the facility and let S1 work for the facility, which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 07/30/2024
Plan of Correction
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Administrator stated to send a plan of correction by the POC due date and associate the staff S1 with the facility immediately.
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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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