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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202774
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:28:35 PM

Document Has Been Signed on 06/22/2023 04:28 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:WARNER HOME #1FACILITY NUMBER:
435202774
ADMINISTRATOR:ARMAND GALLEONFACILITY TYPE:
735
ADDRESS:3710 WARNER DRIVETELEPHONE:
(831) 917-2870
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 6DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Pam SloanTIME COMPLETED:
12:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Licensee (LNS) Pam Sloan, and Administrator (ADM) Armand Galleon.

LPAs checked 5 resident record files (R1 - R5) and 5 staff record files (S1 - S5). 1 resident was observed in the facility, the other 5 residents went to day program. 4 staff were interviewed.

LPA toured the facility inside out with LNS. Living room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towel in kitchen was observed with holder. Three shared resident bedrooms, and laundry room were inspected. Two staff live-in rooms were observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 105 degree F in facility. The temperature of refrigerator was observed at 40 degree F, and the temperature of the freezer was observed at 0 degree F.

Fire extinguisher was serviced on 1/31/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by LNS, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Exit interview was conducted with LNS. The report were provided to LNS for signature. LIC9099-D and Appeal Right were attached. A copy of the report were provide to LNS.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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Document Has Been Signed on 06/22/2023 04:28 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 06/22/2023 at 12:28 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: WARNER HOME #1
FACILITY NUMBER: 435202774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA did not observe locked caninets in kitchen to lock knieve and detergent in the kitchen. Licensee stated knives and detergent were locked in garage. LPA interviewed caregiver (R1), and R1 stated he/she someties put the detergent in the cabinet under the sink and put knieves in drawer by the sink during cooking, and put the knieves and detergent in the garage after cooking.
Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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LIcensee agreed to submit a Plan of Correction by the POC due date to put lock on the cabinet in the kitchen to store knieves and detergent.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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