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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202754
Report Date: 09/17/2025
Date Signed: 09/17/2025 05:24:41 PM

Document Has Been Signed on 09/17/2025 05:24 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:PRIMAVERA GARDENSFACILITY NUMBER:
435202754
ADMINISTRATOR/
DIRECTOR:		MICHAEL ELSOUSOUFACILITY TYPE:
740
ADDRESS:16095 CHURCH STREETTELEPHONE:
(408) 778-5683
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 20CENSUS: DATE:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Lisa Lanford, Resident Care SupervisorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required 1 year annual inspection. LPA met with Administrator, Lisa Lanford.

The facility is currently undergoing a change of ownership and the new owner has submitted an application to the Department which is currently pending. All residents, family and staff were made aware of the upcoming change.

During visit, LPA toured the facility with ADM to include all resident bedrooms, bathrooms, shower room, staff lounge, dining room, living room, kitchen, and laundry room.

Facility temperature maintained at 70 degrees F. Emergency exit doors observed with door alarms. 1 out of 3 of the door alarms which was next to bedroom #1 observed not operable. During visit, the maintenance personnel replaced the battery of the door alarm in which LPA observed the door alarm was operable.

Fire extinguisher last serviced on 10/24/2024. Facility equipped with carbon monoxide detectors in the kitchen and hallways. All resident bedrooms equipped with beds, linens, night stands, dressers, lidded trash bins, and adequate lighting. Residents whose beds are equipped with half rails has a physician order on file for the use of half rails.

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NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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: PRIMAVERA GARDENS
FACILITY NUMBER: 435202754
VISIT DATE: 09/17/2025
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LPA measured the hot water temperature in bedroom #1. LPA observed the sink in bedroom #1 was not properly draining causing the sink to be clogged. The maintenance personnel fixed the sink drainage during visit. The hot water temperature was measured at 119 degrees F.

The hot water temperature in bedroom #9 measured at 133.7 degrees F. Hot water temperature in bedroom #10 measured at 126.5 degrees F. During visit, the maintenance personnel attempted to lower the hot water temperature but then states the knob to adjust the water temperature is broken. The maintenance personnel states to have called a plumber in which the plumber is scheduled to come to the facility the morning of 09/18/2025. In the meantime, the ADM states a plan to measure the hot water temperature in all bathroom sinks and shower room and place caution signs next to the sinks whose hot water temperature exceeds more than 120 degrees F, while the facility is waiting to lower the hot water temperature. A Type A deficiency is being cited today per Title 22 Section 87303(e)(2) for the hot water temperature exceeding more than 120 degrees F in bedroom #9 and #10.

LPA toured the kitchen area. LPA observed a perishable food supply of at least 2 days and a nonperishable food supply of 7 days. Toxins and chemicals are stored separately from the food supply. LPA observed the pilot light of the gas stove is left continuously on. ADM states the brand of the stove is designed to have the pilot light left of on continuously. LPA advised of safety concerns as there were plastic seasoning containers above the stove where the pilot light was on. ADM stated understanding. During visit, the maintenance personnel placed a carbon monoxide detector in the kitchen area.

Refrigerator temperatures maintained at 36 degrees F. Freezer temperature maintained at 0 degrees F. LPA toured the resident dining area. LPA observed a wooden plank in the track of the sliding glass door obstructing the sliding glass door in the dining room. The sliding door leads out to front of facility. A Type A deficiency is being cited today per Title 22 Section 87307(d)(6) wherein the sliding door track in the dining room which leads to the front of the facility was obstructed by a wooden plank which did not allow the sliding door to open freely.
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NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
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: PRIMAVERA GARDENS
FACILITY NUMBER: 435202754
VISIT DATE: 09/17/2025
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5 residents records were reviewed. 5 out of 5 resident records observed complete and up-to-date. ADM states the needs and services plans are verbally reviewed with the resident and families however the new forms that were developed are not being signed. ADM states a plan to revise the needs and services plan to include a signature portion as acknowledgement that the plan was reviewed and agreed upon. 5 residents centrally stored medications and records were reviewed and no issues were noted.

3 staff files were reviewed and the staff files were complete to include a 1st aid certification, health screening, TB result, personnel record and staff training.

Emergency drills are completed quarterly and the last drill was completed on 09/07/2025.
Documents were requested to update the facility file to include by 09/24/2025: Lease agreement, LIC308, liability insurance, LIC500, administrator certificates, and surety bond (if applicable).

Licensee was informed that the annual licensing fee has not been paid as of 09/17/2025.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with ADM Lisa Lanford and a copy of the report and appeal rights was provided.

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NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2025 05:24 PM - It Cannot Be Edited


Created By: Christine Kabariti On 09/17/2025 at 04:56 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: PRIMAVERA GARDENS
FACILITY NUMBER: 435202754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above wherein the hot water temperature was measured at 133 and 126 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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The maintanence personnel called the plumber and the plumber is scheduled to come the morning of 09/18/2025 to inspect the water heater. In the meantime, ADM states a plan to post caution signs at every sink whose water temperature exceeds 120 degrees F. ADM will submit the plumber documentation and a written plan on going forward to LPA Kabariti via email by POC due date.
Type A
Section Cited
CCR
87307(d)(6)
(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above wherein the sliding door in the dining room was obstructed by a wooden plank preventing the sliding door to open freely which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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ADM immediately removed the wooden plank from the sliding door track. ADM will submit a written plan to ensure all exit routes are clear of obstruction to LPA Kabariti via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
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