435202728-9-24-2024-26-AS-MPAA-D9EUW8-20240924155619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202728
Report Date: 09/24/2024
Date Signed: 09/24/2024 03:56:52 PM

Document Has Been Signed on 09/24/2024 03:56 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:	SYCAMORE HOME		FACILITY NUMBER:	435202728
ADMINISTRATOR/ DIRECTOR:	NOEL HUANTE		FACILITY TYPE:	737
ADDRESS:	15160 SYCAMORE AVE		TELEPHONE:	(408) 915-5970
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY: 4		CENSUS: 4	DATE:	09/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	David Sandhu & Noel Huante		TIME VISIT/ INSPECTION COMPLETED:	04:00 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) Maria (Mita) Partoza a conducted an unannounced required 1 year inspection visit and met with Director of Operations (DO) David Sandhu and Noel Huante (ADM) and stated the purpose of the visit. The facility is licensed to serve adults. 18 to 59 4 ambulatory only. The License is subject to the terms and conditions for hospice care for two (2) LPA observed 3 out of 4 residents (R2 to R4) are present at the facility that have neurocognitive impairment. 1 out of 4 is in the day program (R1) There are 6 staff present at the time of the visit. At 10:48 a.m. LPA toured the facility inside and outside with DO and ADM, including but not limited to the kitchen, bathroom, dining room, living room, 4 out of 4 residents rooms, garage, backyard and exterior walkways. The temperature inside the home was at 73 degrees Fahrenheit. The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. Under the sink cabinet is kept locked and not accessible to residents. The water temperature measured at 115.7 degrees Fahrenheit. The facility is maintained, sanitary and organized. Based on the Department of Developmental Services (DDS) audit on 9/10/2024. The following were addressed and inspected during today's visit. The facility's lacks window screen, ADM reported that due to one of the resident (R2) consistently rips the screens off the window. ADM stated that they will get a flexible screens that does not break easily and will be placed on the windows. Currently ADM has a magnetic screen window instead a permanent one. page 1 of 3

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

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 3

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: SYCAMORE HOME	FACILITY NUMBER: 435202728
	VISIT DATE: 09/24/2024

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
26
27
28
29
30
31
32

The cabinets in the dining area, hallway, laundry room have been replaced. The large volume of debris located along the left side of the backyard have been removed and LPA observed the gate towards the driveway is free from obstruction. The missing fence slating by the water tank fence has been replaced. The malfunctioning locking magnet in the laundry room cabinet has been fixed. ADM stated that a work order has been submitted for the cabinet door for lower linen cabinet by the hallway.

ADM stated that the unsafe debris/trash will be stored in a safe location until removal can occur. ADM stated that there are other work orders submitted for repairs and replacements with Bay Area Housing Corporation (BAHC).

The bathroom/s are equipped with grab bars, non-skid mats. The water temperature in the bathroom measured at 115.8 degree Fahrenheit. Resident's room R1 to R4 are equipped with sufficient storage and night stands are in good repair. The hallways are free from obstruction.

LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete and is accessible to staff.

The backyard, walkways, ramps and patio are free from debris and obstruction. The washer and dryer located at the hallway and are in god working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care.

The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition, night lights on the hallway are in good working condition. LPA reviewed the facility file record and observed that disaster fire and earthquake drill training is administered every month.

page 2 of 3

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: SYCAMORE HOME	FACILITY NUMBER: 435202728
	VISIT DATE: 09/24/2024

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
26
27
28
29
30
31
32

LPA reviewed 4 out of 4 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed records are current and updated. LPA reviewed 4 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. All staff have criminal record and fingerprint clearance. Training requirement are met and up to date.

No deficiencies were cited during today's visit based on California Code of Regulation (CCR) Title 22. An exit interview was conducted with Director of Operations David Sandhu and Administrator Noel Huante. A copy of the report was provided.

page 3 of 3
end of report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3