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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202696
Report Date: 11/08/2024
Date Signed: 11/08/2024 08:04:48 PM

Document Has Been Signed on 11/08/2024 08:04 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:HOLLY'S CARE HOMEFACILITY NUMBER:
435202696
ADMINISTRATOR/
DIRECTOR:		ANA LUISA MEJIAFACILITY TYPE:
735
ADDRESS:531 CANTON DRIVETELEPHONE:
(408) 224-3159
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:41 PM
MET WITH:Ana Luisa MejiaTIME VISIT/
INSPECTION COMPLETED:
08:15 PM
NARRATIVE
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Licensing Program Analyst LPA Marcela Yanez, Kenneth Madrigal, and LPM Romeo Manzano conducted an unannounced annual inspection visit, and met with Administrator Ana Luisa Mejia . During the visit, LPA observed 1 residents and 3 staff. This facility serves residents with developmental disabilities, level 4C.

LPA toured the facility inside and out with ADM which included the Living room, kitchen water temperature was measured with digital thermometer at 120.7 degrees F and residents bathrooms #1 at 105.2 f and #3, 104.1 f. During the course of inspection the hot water temperature stabilized at 120 degrees F.

The refrigerator temperature measured at 37 degrees F and Freezer measured at -1 degrees F. LPA observed 2 Fire Extinguisher 1 located in the kitchen dining area, and 1 located at the end of hallway in between bedroom 2 and 3. Fire extinguishers was serviced in 01/29/2024 .

The front yard and backyard were inspected. There was no obstruction to block the walkways/ramp. A locked shed was observed and used for storage and locked and inaccessible to residents.

The two day perishable food supplies and 7 day nonperishable food supplies were observed and adequate. Facility medication storage area, knives storage area, and cleaning product storage area were locked and inaccessible to residents in care.

The facility has an Air conditioner, and a Van to transport residents and is in good working condition. The facility also has a new roof.

The staff bedrooms (formerly garage) is located at the front of the facility wherein it will be hard for staff to hear any commotion or residents behavior from residents bedrooms. ADM stated that staff bedrooms are open during the night so they can hear residents and also staff sleeps in the living room. LPAs informed ADM that staff is not allowed to be sleeping in the living area. ADM agreed and understood. No deficiency cited.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: HOLLY'S CARE HOME
FACILITY NUMBER: 435202696
VISIT DATE: 11/08/2024
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While touring the facility LPAs observed 2 tide detergents near staff bedrooms which is accessible to residents. ADM placed detergents in a locked laundry area during visit.

During inspections of residents' bedrooms had mouth wash and foot lotion with active ingredients and any items with a warning on label such as "keep reach out of children.". LPAs advised ADM to keep them inaccessible to residents. ADM agreed and understood.

Room temperature was 71 degrees F. LPA observed window screen door and sliding door in bedroom #2 and #3 tears and holes. LPA observed between bedroom#2 and the ramp has a rotten wood. ADM stated she spoke with contractor and scheduled an appointment for repair.

The facility has 6 centrally wired smoke/carbon monoxide detectors and 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 06/29/2024.

During inspection of facility exits, LPAs observed an additional bedroom (used to be part of the playroom) that is not on the physical floor plan ADM stated they built additional room in accordance with HCBS for privacy such as regional center meetings and medication administration. The additional room has a door leading to the exit door which causes an obstruction and is equipped with a locked doorknob.

LPAs reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records including P& I. LPAs interviewed 2 staff and 2 residents.

Deficiencies cited during today's visit. This report was reviewed/discussed with ADM Ana Luisa Mejia and a copy of the signed report was provided. A copy of appeal rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/08/2024 08:04 PM - It Cannot Be Edited


Created By: Marcela Yanez On 11/08/2024 at 06:33 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: HOLLY'S CARE HOME
FACILITY NUMBER: 435202696

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)

c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction

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 blocking the Exit in bedroom #3 with a stick on the outside between the window track. Which did not allow screen door to open when exiting. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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During todays visit the Administrator removed stick and stated she will not obstruct the exit with any object and instruct staff to make sure all designated exits are free of obstruction corrected today.
Type A
Section Cited
CCR
80087(g)(1)
(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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 storing laundry detergent near the staff bedrooms and pantry which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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ADM removed the 2 laundry detergent and locked it and corrected deficiency today.
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: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/08/2024 08:04 PM - It Cannot Be Edited


Created By: Marcela Yanez On 11/08/2024 at 07:25 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: HOLLY'S CARE HOME
FACILITY NUMBER: 435202696

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
(a)Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and facility sketch the licensee did not comply with the section cited above by altering the facility by adding an additional room which was a play room and divided into 2 rooms without a fire clearance and building permit which poses/posed a potential health, safety or personal rights risk to persons in care.

POC Due Date: 11/13/2024
Plan of Correction
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ADM stated she will consult with fire department if it requires a permit and fire clearance. and will replace it room dividers and new floor plan sketch.
Type B
Section Cited
CCR
80088(b)
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed window screen door and sliding door in bedroom #2 and #3 tears and holes. LPA observed between bedroom#2 and the ramp has a rotten wood. ADM stated she spoke with contractor and scheduled an appointment for repair.
POC Due Date: 11/13/2024
Plan of Correction
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ADM stated she will replace sliding door screens and repair rotten wood.
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: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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