435202750-1-22-2025-26-AS-KJAN-DD6SSQ-20250122130818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202750
Report Date: 01/22/2025
Date Signed: 01/22/2025 01:08:41 PM

Document Has Been Signed on 01/22/2025 01:08 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:	MAGDALENE RESIDENTIAL CARE II		FACILITY NUMBER:	435202750
ADMINISTRATOR/ DIRECTOR:	LITERATO-HILARIO, FE		FACILITY TYPE:	740
ADDRESS:	1107 E. HOMESTEAD ROAD		TELEPHONE:	(408) 564-0423
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Elsa Lopez, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	01:20 PM

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On January 22, 2025, at 08:50 AM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the caregiver, Elsa Lopez, and disclosed the purpose of the inspection. The caregiver informed the LPA that the facility had (6) residents in care and (3) staff members present at the time. LPA observed (2) staff members in the kitchen preparing breakfast and (1) staff member assisting residents with the breakfast on the dining table.

At 9:24 AM, the LPA initiated a walk-through of the facility, accompanied by the caregiver.

LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. The LPA observed (5) residents eating breakfast at the dining table.

LPA inspected the living room and observed it clean, with all furniture in good repair. There were reclining chairs and a television in the living room. LPA inspected the fire extinguisher mounted on the wall in the living room and found it fully charged, with the last service tag dated 04/09/2024. The caregiver tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional.

There were (6) bedrooms and (2½) bathrooms designated for residents' use. All resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. LPA observed scissors on a table in room #1 and another scissors on top of chest in room #3, accessible to residents. LPA inspected (2) full bathrooms and found them clean, sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip mats. The hot water temperature at the sink faucet measured 108.5°F in bathroom #1 and 109.2°F in bathroom #2.

Continued on 809-C

April Cowan	TELEPHONE: (650) 266-8889
Kiran Jain	TELEPHONE: (650) 416-4836
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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: MAGDALENE RESIDENTIAL CARE II	FACILITY NUMBER: 435202750
	VISIT DATE: 01/22/2025

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LPA inspected the kitchen and found it clean, with breakfast preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet containing knives and sharp objects, and a locked cabinet under the sink with detergents and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted.

LPA inspected the storage closet in the hallway and observed it contained clean linens, blankets, and towels for residents’ use.

LPA inspected the garage and found it clean. A washer, a dryer, a freezer containing additional food supplies, and a closet containing detergents and paper products were observed.

LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No bodies of water were noted. The LPA inspected (2) storage sheds and observed wheelchairs, furniture items, bedframes, mattresses, outdoor furniture, outdoor heaters, and PPE products stored in the sheds. Auditory alarms was observed to be working on all the exit doors.

LPA reviewed (6) staff personnel records and (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. 1 of 5 residents (R4) was missing a completed safeguards for property/valuables form. 1 of 5 residents (R2) was missing personal rights forms. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility.

LPA observed a locked centrally stored medication cabinet inside the kitchen. Medications were organized in separate bins for each resident. 6 of 6 resident medication prescription labels were altered with the handwritten notes using a black marker pen. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 11/20/2024.

Continued on 809-C

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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: MAGDALENE RESIDENTIAL CARE II	FACILITY NUMBER: 435202750
	VISIT DATE: 01/22/2025

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The following updated forms are requested to be submitted to CCLD by 01/29/2025:

LIC 500: Personnel Report
LIC 308: Designation of Facility Responsibility
LIC 999: Facility Sketch (Floor Plan)
Certificate of Liability Insurance
Current Property Lease Agreement
Administrator Certificate(s)

A deficiency is being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the caregiver. A copy of this report and appeal rights were discussed and left with the caregiver, Elsa Lopez, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 01/22/2025 01:08 PM - It Cannot Be Edited

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: MAGDALENE RESIDENTIAL CARE II	FACILITY NUMBER: 435202750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure that scissors are not accessible to 6 of 6 residents (R1-R6) in 2 of 6 rooms poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2025
	Plan of Correction
1 2 3 4	The licensee will remove scissors and other sharp objects from all (6) resident rooms and keep them locked, unaccessible to the residents in care and will submit a plan of action understanding the regulation to CCLD by 01/29/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

April Cowan	TELEPHONE: (650) 266-8889
Kiran Jain	TELEPHONE: (650) 416-4836
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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