435202785-12-29-2025-26-AS-MPAA-DPU3R8-20251229172820

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202785
Report Date: 12/29/2025
Date Signed: 12/29/2025 05:28:44 PM

Document Has Been Signed on 12/29/2025 05:28 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	AFRA RESIDENTIAL CARE HOME		FACILITY NUMBER:	435202785
ADMINISTRATOR/ DIRECTOR:	PONGYAN, JOELITO		FACILITY TYPE:	735
ADDRESS:	686 ARDIS AVE		TELEPHONE:	(408) 247-1101
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY: 6		CENSUS: 6	DATE:	12/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Joelito Pongyan - ADM		TIME VISIT/ INSPECTION COMPLETED:	05:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maria (Mita) Partoza a conducted an unannounced required 1 year inspection visit and met with licensee/administrator (LIC/ADM) Joelito Pongyan and stated the purpose of the visit. The facility is licensed to serve adults 18 to 59. 4 ambulatory and 2 non-ambulatory (bedroom #1 only).LPA observed 5 out of 6 residents are present at the facility that are developmentally challenged and 1 out of 6 is not present at the facility due to medical condition. 3 staff were present at the time of the visit. At 2:15 p.m. LPA toured the facility inside and outside with staff 1, including but not limited to the kitchen, bathroom, dining room, living room, 3 out of 3 residents rooms, 1 staff room, garage, backyard and exterior walkways. The temperature inside the home was at 70 degrees Fahrenheit. The facility was observed to be maintained, sanitary and organized. The hallways and walkways are free from obstruction. The facility screen windows and doors were observed to be in good repair. The exit doors are not obstructed, no tripping hazard was observed. The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. Under the kitchen sink cabinet is use to store chemicals and kept locked and not accessible to residents. The kitchen water temperature was measured with a digital thermometer at 139.6 degrees Fahrenheit. page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025

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: AFRA RESIDENTIAL CARE HOME	FACILITY NUMBER: 435202785
	VISIT DATE: 12/29/2025

NARRATIVE

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The bathroom/s are equipped with grab bars, anti skid mats. The water temperature in 2 out of 2 bathrooms when measured with a digital thermometer is between 136.5 to 137.5 degree Fahrenheit. 3 Out of 3 residents room have sufficient storage and sufficiently lighted.

LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete with the guide book and is accessible to staff.

The washer and dryer are in good working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care. The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition. The facility is equipped with a fire extinguisher inspected on 08/18/2025.

LPA reviewed 5 out of 5 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), personal and incidental allowance, admission agreement, needs and services plan, health screening and observed records to be updated and current .

LPA reviewed 3 out of 12 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. All staff have criminal record clearance/fingerprints.

Deficiency is cited during today's visit based on California Code of Regulation (CCR) Title 22 80088(e)(1). An exit interview was conducted with administrator Joelito Pongyan. A copy of the report and appeals rights were provided.

End of Report
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/29/2025 05:28 PM - It Cannot Be Edited

Created By: Maria Partoza On 12/29/2025 at 05:04 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: 12/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

80088 Furniture, Fixtures, Equipment, and Supplies (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation LIC/ADM did not comply with the section cited above by not ensuring the water temperature used by clients for personal care is maintained at 105 to 120 degree F. The water temperature in 2 out of 2 resident bathrooms & kitchen is at 136.5 to 139.6 degree F when measured with a digital thermometer which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2025
	Plan of Correction
1 2 3 4	ADM stated that he/she will submit a written plan of correction to address the water temperature to ensure that it complies with Title 22 regulation. The written plan of correction will be submitted to LPA by POC due date of 12/30/2025.

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.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025

LIC809 (FAS) - (06/04)

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