<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202673
Report Date: 12/29/2022
Date Signed: 12/26/2023 04:58:56 PM

Document Has Been Signed on 12/26/2023 04:58 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:LA PAZ RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202673
ADMINISTRATOR:JAURIQUE, BETTY JEANFACILITY TYPE:
735
ADDRESS:356 MADISON DRTELEPHONE:
(408) 674-9610
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Betty Jean JauriqueTIME COMPLETED:
02:39 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 Ryker Heberle (LPA) conducted an unannounced annual inspection on 12/29/2022 at 12:58pm. LPA met with facility Administrator Betty Jean Jaurique (Admin).

LPA toured the facility, including living room, dining room, kitchen, 1 staff bedroom, 3 resident bedrooms, 2 bathrooms, back yard, and garage. No staff members observed to be wearing masks, but all facility staff and residents were tested that morning. Admin confirmed that all staff and residents have been vaccinated.

Facility observed to have designated entry point with sign in process. No signs were posted at the front of the facility. Admin took LPA's temperature but did not screen for symptoms. 30 day supply of PPE observed. Restrooms were stocked with paper towels for hand washing. Hand washing signs were not observed to be posted in all public bathrooms. Social distancing signs not posted in public areas. The facility is currently accepting visitors inside the facility, including residents' bedrooms.

Facility infectious control plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be adequately clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Facility carbon monoxide detector observed. Facility water temperature observed to be at 136.9 *F.

Deficiency cited during today's visit. Advisory notes issued. This report was reviewed with Administrator Betty Jean Jaurique (Admin) and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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 12/26/2023 04:58 PM - It Cannot Be Edited


Created By: Ryker Heberle On 12/29/2022 at 02:27 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: LA PAZ RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202673

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 - Maintenance and Operation - (e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the restroom water temperature was measured at 136.9*F, 16.9*F over the limit. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
1
2
3
4
Licensee adjusted water temperature while LPA was at the facility. Licensee to provide photographic proof of correction by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2