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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202785
Report Date: 12/20/2024
Date Signed: 12/20/2024 02:37:42 PM

Document Has Been Signed on 12/20/2024 02:37 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:AFRA RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202785
ADMINISTRATOR/
DIRECTOR:		ARINES, DIOSDADO EMMANUELSFACILITY TYPE:
735
ADDRESS:686 ARDIS AVETELEPHONE:
(408) 247-1101
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 6CENSUS: 5DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Farnoosh EbadatTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analysts (LPA) Santino Fortes and LPM Jackie Jin conducted an unannounced annual inspection, and met with Licensee Farnoosh Ebadat and ADM Joel Pongyan. ADM informed that facility has 2 staff and 5 clients.

LPAs toured the facility inside out including: kitchen, living room, 3 resident rooms, office, and 3 restrooms. Restrooms observed to have non skid flooring. LPAs observed perishable food supply of at least two days and non-perishable food supply of at least 3 days. Refrigerator temperature was observed at 44.0 degrees F and Freezer temperature was 0 Degrees F. During visit ADM stored the laundry soap in a locked cabinet in the garage to correct. The front yard and backyard of the facility was also inspected. There was no obstruction to block the outdoor exits. Old furnitures were observed outside the side gate. ADM was informed to remove the items and keep the exit areas clear of debris. Storage room in the garage was observed to be used as a staff rest area containing beds and personal items. ADM was informed that storage areas are not to be used for any other purposes other than storage.

Facility License and Resident Personal rights were posted. LPA observed the medication storage area, knives storage area, and cleaning product storage area are locked and inaccessible to clients in care. Room temperature was at 72.1 degree F, and hot water temperature was measured from resident bathroom at 128.6 degrees F. ADM adjusted the water heater setting and water temp was 116.4 degrees F. LPA inspected the facility first aid kit and it was observed to be complete. The facility was equipped with smoke / carbon monoxide detectors and functioned properly when tested. Fire extinguishers were last serviced on 8/2/24. The facility conducted their last fire drill on 8/16/24.

LPA reviewed facility records for 3 staff and 5 clients. All staff have criminal record clearance. LPA reviewed 5 clients medications and centrally stored medication records and observed to be correct.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Santino Fortes
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 13
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: AFRA RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202785
VISIT DATE: 12/20/2024
NARRATIVE
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This document was created in error and this page is left blank intentionally.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Santino Fortes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC809 (FAS) - (06/04)
Page: 11 of 13
Document is an Amendment of Original Document on 01/06/2025 03:12 PM


Created By: Santino Fortes On 12/20/2024 at 01:44 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: AFRA RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type A
Section Cited
CCR
85087(a)(3)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Jackie Jin
LICENSING EVALUATOR NAME:Santino Fortes
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
Page: 9 of 13
Document is an Amendment of Original Document on 01/06/2025 04:08 PM


Created By: Santino Fortes On 12/20/2024 at 01:47 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: AFRA RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
Type A
Section Cited
CCR
85087(a)(3)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Jackie Jin
LICENSING EVALUATOR NAME:Santino Fortes
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
Page: 10 of 13
Document Has Been Signed on 12/20/2024 02:37 PM - It Cannot Be Edited


Created By: Santino Fortes On 12/20/2024 at 01:54 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: AFRA RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(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 observations, the licensee did not comply with the section cited above by not ensuring the facilty was clean and in good repair at all times. LPA and LPM observed side exit gate not opening freely and dragging on the ground. The closet sliding door was not opening properly because of a missing wheel. LPA observed a hole in the wall created by the door handle and hinge, and debris stored on the side of the facility,which poses an immediate health risk to residents.
POC Due Date: 12/21/2024
Plan of Correction
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Licensee shall develop a plan of action to ensure the facility is clean, safe, sanitary, and in good repair at all times. Licensee agreed to repair the damage from the, the hole in the wall, broken hindge, replace the broken dresser, repair the closet door, and remove the debris. Licensee shall submit a plan and pictures to CCL by POC date.
Type A
Section Cited
CCR
85087(a)(3)(A)
No room commonly used for other purposes shall be used as a bedroom for any person. Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings. 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 which a storage area in the garage was observed to be used as a staff room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2024
Plan of Correction
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Licensee shall develop a plan of action to ensure storage areas are not used as a bedroom for anyone. Licensee agreed to have the staff move out of the storage area. Licensee shall submit a plan and a picture to CCL 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.
SUPERVISOR'S NAME:Jackie Jin
LICENSING EVALUATOR NAME:Santino Fortes
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
Page: 12 of 13
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: AFRA RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202785
VISIT DATE: 12/20/2024
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Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Joel Pongyan and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Santino Fortes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC809 (FAS) - (06/04)
Page: 13 of 13