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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202816
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:28:49 PM

Document Has Been Signed on 09/12/2024 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SHIRAN CARE MANAGEMENT INC.FACILITY NUMBER:
435202816
ADMINISTRATOR/
DIRECTOR:		AIDA,URENAFACILITY TYPE:
735
ADDRESS:545 BISCAYNE CTTELEPHONE:
(408) 649-8537
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 6CENSUS: 6DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Aida UrenaTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1 - year annual inspection. LPA met with Administrator (ADM), Aida Urena.

During visit, LPA toured the facility with ADM to include the resident bedrooms, bathrooms, living room, kitchen, garage, and backyard. The shed in the backyard observed with storage items. There were 3 staff present during visit. All fire exit routes are free and clear of obstruction. Facility temperature maintained at 75 degrees F. Fire extinguisher purchased on 04/28/2024. Carbon monoxide present. Hot water temperature maintained at 108 degrees F.

Resident bedrooms equipped with beds, linens, dressers, and adequate lighting. Bathrooms equipped hygiene items. Chemicals, disinfectants and sharp objects observed locked.

Kitchen equipped with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Items inside the refrigerator observed covered and labeled. Refrigerator temperature maintained at 46 degrees F. Freezer temperature maintained at 10 degrees F. Items inside the freezer observed frozen and cold. Administrator states the thermometer might broken and will purchase a new one. Facility has emergency go bags located next to the front entrance. LPA observed the facility has emergency lighting. First aid kit observed.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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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: SHIRAN CARE MANAGEMENT INC.
FACILITY NUMBER: 435202816
VISIT DATE: 09/12/2024
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LPA reviewed 3 resident records. Resident records contains an admission agreement between SARC, consumer and facility, medical assessment, TB result, appraisal/needs and services plan, consent forms, and personal rights. LPA did not observe an admission agreement between the facility and resident for 3 residents. LPA advised the Licensee to complete and review an admission agreement that was submitted and approved by Licensing, with the resident and/or resident's authorized representative.

LPA reviewed 3 staff files to include a 1st aid certification, fingerprint clearance, health screening, TB result, and personnel report. Facility staff are provided annual training. LPA observed 1 staff had a TB result but did not have a health screening report on file. ADM states the staff completed a health screening and will obtain the health screening report.

Posters observed to include the facility license, complaint poster, personal rights, and COVID-19 related posters.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note provided.

This report was reviewed with Administrator, Aida Urena and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2024 04:28 PM - It Cannot Be Edited


Created By: Christine Dolores On 09/12/2024 at 03:59 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: SHIRAN CARE MANAGEMENT INC.
FACILITY NUMBER: 435202816

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 counts in which the licensee did not complete an admission agreeement that was approved by the Department between the facility and resident for 3 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Licensee will submit a written plan to ensure all residents completes an admission agreeement that was approved by the Department. Licensee will submit the POC to LPA Dolores via email by POC due date of 09/19/2024.
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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