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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202674
Report Date: 02/09/2024
Date Signed: 02/09/2024 03:34:54 PM


Document Has Been Signed on 02/09/2024 03:34 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:ROSE GUEST HOMEFACILITY NUMBER:
435202674
ADMINISTRATOR:SACUN, LILIANFACILITY TYPE:
740
ADDRESS:1820 BETHANY AVETELEPHONE:
(408) 649-6532
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:6CENSUS: 5DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator Lilian SacunTIME COMPLETED:
03:40 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) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Lilian Sacun. During the visit, LPA observed 4 residents and 2 staff.

LPA toured the facility inside out with Staff S3, which included the Living room, kitchen, dining room, 2 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring facility bedrooms, LPA observed bedroom #3 at approximately 1pm. S3 stated bedroom #3 is a staff bedroom. LPA observed the door to bedroom #3 does not have a lock. LPA observed a medication container on the dresser. (Photographs were taken.)

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 72 degrees F, and hot water temperature was measured at 110 degrees F in both resident bathrooms.

Fire extinguisher was serviced in August 16, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on February 3,2024.

LPA reviewed facility records for 3 staff . While reviewing S3's file, LPA asked ADM for S3's training for 2023. ADM stated she did train S3 but she did not document any of S3's training's for 2023.

Page 1 out of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
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 4