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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202674
Report Date: 02/14/2025
Date Signed: 02/14/2025 12:19:24 PM

Document Has Been Signed on 02/14/2025 12:19 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:ROSE GUEST HOMEFACILITY NUMBER:
435202674
ADMINISTRATOR/
DIRECTOR:		SACUN, LILIANFACILITY TYPE:
740
ADDRESS:1820 BETHANY AVETELEPHONE:
(408) 649-6532
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 5DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator/Licensee Lilian SacunTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Lilian Sacun, Administrator/Licensee (ADM/LIC). LPA announced the purpose of the visit. LPA observed 2 staff and 5 residents.

During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies.

During tour LPA observed a bottle of Cleaning Spray (Photo Taken) in unlocked cabinet under sink accessible to residents in care. S1 removed Cleaning Spray and placed it in locked closet.

LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature was measured with thermometer at 37 degrees and freezer at 0 degrees F.

LPA observed Posters, ADM certificate and License posted in the facility as well as and Residents Rights.

LPA toured 4 resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights.

While touring resident bedroom LPA observed a medication Inhaler and Eye Drops and and Over the Counter medication belonging to a resident R3 accessible to residents in care. S1 removed medication and placed it in Centrally Stored Medication Closet.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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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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: ROSE GUEST HOME
FACILITY NUMBER: 435202674
VISIT DATE: 02/14/2025
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LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 116-120 degrees F.

ADM tested the smoke detector in the hallway and found the smoke detector to function properly when tested. Facility has a Fire Pull Alarm which was serviced 09/2024.

LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last purchased on 07/12/2024. LPA reviewed Fire and Earthquake log and last disaster drill was conducted on 01/31/2025

LPA reviewed resident records for 3 residents. LPA reviewed 3 staff records. LPA reviewed Centrally Stored Medication for 3 residents with S1.

Deficiency was cited as per California Code of Regulations Title 22. This report was reviewed with ADM/LIC and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2025 12:19 PM - It Cannot Be Edited


Created By: Marcela Yanez On 02/14/2025 at 11:50 AM
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: ROSE GUEST HOME
FACILITY NUMBER: 435202674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(c)
Storage Space and Access
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

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 in by storing Cleaning Spray unlocked under kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2025
Plan of Correction
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ADM/LIC will submit of plan of correction a letter of understanding of regulation title 22 via email to LPA via email by POC date of 02/15/2025
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by storing prescribed medication and OTC in residents bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2025
Plan of Correction
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ADM/LIC will submit of plan of correction a letter of understanding of regulation title 22 via email to LPA via email by POC date of 02/15/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
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