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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202774
Report Date: 05/31/2024
Date Signed: 06/01/2024 09:46:30 AM

Document Has Been Signed on 06/01/2024 09:46 AM - 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/
DIRECTOR:		ARMAND GALLEONFACILITY TYPE:
735
ADDRESS:3710 WARNER DRIVETELEPHONE:
(831) 917-2870
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 6DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Elena ButayaTIME VISIT/
INSPECTION COMPLETED:
04:38 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House manager (HM) Elena Butaya.

LPA observed 3 staff and 6 residents in the facility.

LPAs checked 3 resident record files (R1 - R3) and 3 staff record files (S1 - S3).

LPA toured the facility inside out with HM. Living room, kitchen, dinning room and two restrooms were inspected. Three shared resident bedrooms, garage, 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, knives closet, and dish washing soap closet were observed locked. Room temperature was at 69 degree F, and hot water temperature was at 110 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. First aid box, flash lights and emergency lights were observed in the facility.

Fire extinguisher was observed expired. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by staff, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. Two storage rooms were observed in the backyard. The last time the facility conducted the emergency drill is 5/4/2024.

Exit interview was conducted with HM. The report were provided to HM for signature. LIC9099-D and Appeal Right were attached. A copy of the report were provide to HM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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 06/01/2024 09:46 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 05/31/2024 at 04:18 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: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the fire extinguisher was observed expired in 2023 which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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House Manager stated to submit a plan of correction by the POC due date to check and maintain the fire extinguisher valid.

The facility staff bought new fire extinguisher from home depot and installed it before LPA finished the inspection.
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: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
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