435202728-9-25-2025-26-AS-MPAA-DLUQLP-20250925121616

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202728
Report Date: 09/25/2025
Date Signed: 09/25/2025 12:16:34 PM

Document Has Been Signed on 09/25/2025 12:16 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:	09/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Noel Huante - Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:00 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 conducted an unannounced required 1 year inspection visit and met with Director of Operations (DO) David Sandhu, administrator Noel Huante (ADM) and Jovana McGraw, back-up Program Administrator (PA). LPA stated the purpose of the visit. The facility is licensed to serve adults. 18 to 59 and ambulatory. The License is subject to the terms and conditions for hospice care for two (2). LPA observed 8 staff at the facility at the time of the visit. At 10:15 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 69 degrees Fahrenheit. LPA measured the water temperature. LPAs water temperature reading is from 108.7 to 116.9 degrees Fahrenheit. Facility retains weekly water temperature log. 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. Facility keeps an inventory log of their sharps. Cintas inspected fire extinguishers on 08/06/2025. The facility's smoke and carbon monoxide alarm system are in good working condition. page 1 of 3

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

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: SYCAMORE HOME	FACILITY NUMBER: 435202728
	VISIT DATE: 09/25/2025

NARRATIVE

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Based on the Department of Developmental Services (DDS) audit conducted on May 2025. The following were addressed and inspected during today's visit.

• Several windows are missing window screens - no missing screens were observed, screens were replaced. • The hallway cabinet is missing a door - repair order is in placed.
• The exterior vent in the backyard is broken and pushed inward towards the wall - this was addressed by the facility.
• There is one fence slat board missing from the backyard fence - no missing slat was observed.
• There is a hole in the hallway wall approximately four inches in length by three inches wide - no hole was observed in the hallway walls.
• There are two walls in the dining/living room area that have multiple small holes (approximately. ½ to 1 inch in diameter) - Facility repaired and address the deficiency. No holes were observed.
• The wall in bathroom #1 has two small holes above where the toilet paper dispenser was previously located - Facility repaired and address the deficiency. No holes were observed.
• The light fixture in bathroom #2 was cracked and split on both sides of the lighting fixture Facility repaired and address the deficiency.
• One plank from the wood floor was loose and lifting from the floor, in one Individual’s bedroom. Creating a trip/fall hazard- Facility repaired and address the deficiency it has been removed and repaired.

The bathroom/s are equipped with grab bars, non-skid mats. 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 good working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

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: SYCAMORE HOME	FACILITY NUMBER: 435202728
	VISIT DATE: 09/25/2025

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LPA reviewed 4 resident files such as but not limited to the Centrally Stored Medication and Destruction Record (CSMDR), admission agreement, health screening, physician's report, personal and incidental, and individual service plans. LPA found records to be updated and current.

LPA reviewed 4 staff files such as but not limited to the background clearance, 1st Aid/CPR requirement certificate, health screening, personnel information and training. Based on file review, fire and drill evacuation training is conducted two times a month by the facility.

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.

End of Report
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

LIC809 (FAS) - (06/04)

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