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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202673
Report Date: 12/08/2025
Date Signed: 12/08/2025 05:56:21 PM

Document Has Been Signed on 12/08/2025 05:56 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/
DIRECTOR:		JAURIQUE, BETTY JEANFACILITY TYPE:
735
ADDRESS:356 MADISON DRTELEPHONE:
(408) 674-9610
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
12/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:45 AM
MET WITH:Allie Jarique and Kristina OgleTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Required 1 Year visit and was met by 2 staff Kristina Ogle and Alexandria Jaurique and stated the purpose of the visit. Administrator Betty Jean Jaurique was not available at the time of the visit due to current health condition.

The facility serves 18 to 59 years old who are ambulatory and are developmentally challenged. LPA observed 2 staff and 5 out of 5 residents were attending the day program at the time of the visit. LPA inspected the facility inside and outside. Inspected 3 resident rooms, 1 staff room, office area, 2 bathrooms, 2 living area, kitchen and garage.

LPA inspected the exterior walkways and observed walkways were free from obstruction, the backyard grass area was uneven, broken fence was observed at the end of the property line, 2 sack of Miracle Gro plant food fertilizer was observed on the ground. LPA observed 2 outdoor heater, patio furniture and painted pumpkins on the ground.

LPA inspected the kitchen and observed the following, under the sink cabinet, was a baby lock that holds together the handle, one of the cabinet door handle was broken and kept the cabinet unlocked. Chemicals were observed stored inside the cabinet (Clorox bleach, Windex, Soft Scrub, Cascade dishwashing soap) and are easily accessible to residents. LPA observed that 3 knives were in the right drawer cabinet next to the dishwasher and accessible to residents in care. Staff removed the knives and placed it in a locked cabinet.
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2025
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: LA PAZ RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202673
VISIT DATE: 12/08/2025
NARRATIVE
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LPA observed upright refrigerator freezer combination with 2 days of perishable food supply. The refrigerator temperature was measured at 38 degree F and freezer at 0 degree F. The kitchen sink water temperature is at 125.4 degree when measured with a digital thermometer. No warning sign was posted stating that the water temperature exceeds 125 degree F

LPA inspected the interior hallways, 2 living area and dining area, and observed no obstruction. LPA observed a small pet feeding bowl in the middle of the living area across the entry way.

LPA inspected 1 resident bathroom and 3 resident bedrooms, 1 of the resident bedroom is shared with staff and 2 out of 3 resident rooms are shared. LPA observed that 1 Out of the 3 resident room has a ammoniac like smell. LPA observed 3 out of 3 resident rooms has sufficient storage for resident's personal belongings and working light. LPA observed non-skid mats and grab bars inside the residents bathroom. The bathroom water temperature is at 122.9 degree F when measured with a digital thermometer.

LPA with 2 staff tested the monoxide detectors and smoke alarms and verified that it is in good working condition. The facility is equipped with a fire extinguisher and was last inspected on 4/9/2024.

LPA inspected the garage area and observed washer and dryer were in good working condition. LPA observed 1 upright freezer containing 2 days of perishable food. LPA observed 7 days of non-perishable food. LPA observed a jar of Grey Poupon Dijon mustard was sealed with expiration date of 05/02/2022, LPA observed 1 dented can of sliced peaches with best if used by 08/28/2024, a jar of Best Foods Garlic Aioli dip and spread with best if used by 07/13/2024, a bottle of French's Organic Mustard with Best by 08/05/2024.

LPA reviewed 5 Out of 5 resident files. The following were reviewed but not limited to Centrally Stored Medication and Destruction Record (CSMDR). Personal and Incidental (P&I) allowance, appraisal needs and services plan (LIC 625), medical assessment, individual program plan (IPP), clients/resident property and valuables (LIC 612) and personal rights (LIC 613). Based on review, 1 out of 5 resident record does not have a current CSMDR, 1 out of 5 LIC 625 was completed on 04/05/2019. 2 out of 5 IPP expired in 2020 & 2022. 2 Out of 5 is missing LIC 613, and 2 out of 3 is missing LIC 621. LPA verified 5 Out of 5 resident P&I are updated and current.
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: LA PAZ RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202673
VISIT DATE: 12/08/2025
NARRATIVE
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LPA reviewed 2 Out of 2 staff record. Based on review, 2 out of 2 have are associated and have criminal and fingerprint clearance and updated 1st/aid CPR certificates. 2 out of 2 are missing Health Screening (LIC 503), 1 out of 2 is missing SOC341A (mandated reporter), 1 out of 2 is missing proof of TB test. 1 out of 2 is missing proof of training. 2 out of 2 are missing personnel record (LIC 501).

LPA reviewed the facility file. Based on review, the facility has fire, earthquake and disaster drill training done each month beginning 01/2025 up to 09/2025.

LPA is not able to conduct interview with any of the residents. Resident were attending day program at the time of the visit. LPA was able to interview 2 of the staff. 1 out 2 staff stated that administrator (ADM) has plans of retiring within a year or two.

LPA requested for the following documents:

Lease agreement
Surety bond
LIC 500: List of personnel
LIC 400: Resident's Cash Resources
Certificate of Liability Insurance
Surety Bond
Administrator Certificate

Deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. Tecnical assistance was provided and LPA informed staff and suggested to contact Technical Support Program.
See LIC 809D for cited deficiencies. An exit interview was conducted with Staff/Designated Administrator Alexandria Jaurique and a copy of the report and appeals rights were 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: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 12/08/2025 05:56 PM - It Cannot Be Edited


Created By: Maria Partoza On 12/08/2025 at 01:38 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: 12/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring chemicals are not readily available & not accessible to clients. The cabinet under the sink does not have a lock and contains cleaning supplies (Clorox Bleach,Softscrub,Windex, cascasde dishwashing detergent, 2 sacks of Miracle Gro in the backyard) that are easily accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2025
Plan of Correction
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Designated administrator/Staff 1 (DADM/S1) stated that he/she will inform administrator Betty Jean Jaurique and will submit a written plan of correction to address the lock and handle of the cabinet under the sink by POC due date of 12/09/2025.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not maintaining water temperature of not less than 105 degree F and not more than 120 degree F. When mesaured with a digital thermometer, the water temperature in the bathroom and kitchen sinks was at 122.9 to 125.4 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2025
Plan of Correction
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Designated administrator/Staff 1 (DADM/S1) stated that he/she will inform administrator Betty Jean Jaurique and will submit a written plan of correction to address the water temperature to comply with regulations standard of 105 to 120 degree F by POC due date of 12/09/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/08/2025 05:56 PM - It Cannot Be Edited


Created By: Maria Partoza On 12/08/2025 at 02:26 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: 12/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(1)to(11)
80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee (1) to (11)

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. Licensee did not ensure records are maintained for 2 out of 2 staff. 2 out of 2 staff has missing documents on record such as but not limited to health screening, training record, proof of TB testing, personel record (LIC 501), LIC 508, SOC 341 (mandated reporter) to complete required information on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Designated Administrator/Staff 1 stated that he/she will inform administrator/licensee of the required documents to be maintained at the facility and will submit a proof of correction by the POC due date of 12/19/2025
Type B
Section Cited
CCR
80069(e)
80069 Client Medical Assessment (e) The licensing agency shall have the authority to require the licensee to obtain a current written medical assessment, if such an assessment is necessary to verify the appropriateness of a client's placement.

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 by not obtaining a current written medical assessment of 1 Out of 5 (R5). R5'S LIC602 medical assessment was last done on 02/07/2020. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Designated adminstrator/staff 1 stated that he/she will inform administrator/licensee of the need to get R's medical assessment updated and will submit proof of correction by the POC due date of 12/19/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 12/08/2025 05:56 PM - It Cannot Be Edited


Created By: Maria Partoza On 12/08/2025 at 02:50 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: 12/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored
(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year.

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 by not maintaining 2 out of 2 (R4 & R5) CSMDR. S1/DADM stated that R4 has no prescription medication, but has OTC medication, therefore, no CSMDR was genearted. R5s CSMDR was not completed because R5 brought the medications with her and S1 could not complete the CSMDR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Designated administrator / Staff 1 stated that he/she will let the administrator/licensee know that records needs to be updated and completed and will submit proof of correction by the POC due date of 12/19/2025.
Type B
Section Cited
CCR
85068.3(a)
85068.3 Modifications to Needs and Services Plan (a)The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

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 by not updating as frequently as necessary 3 out of 5 (R1, R4, R5) resident's appraisal needs and services plan (LIC 625). Based on recored review R1 IPP expired on 2022, LIC 625 03/31/2024, R4 IPP expired 08/12/2019, LIC 625 is missing. R5 LIC 625 last completed on 04/05/2019 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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2
3
4
Designated administrator/Staff 1 stated that he/she will let administrator/licensee of the need to update the needs and services plan of R1, R4, and R5 and will submit proof of correction by 12/19/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2025


LIC809 (FAS) - (06/04)
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