435202816-9-24-2025-26-AS-CKAI-DLTRYY-20250924132708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202816
Report Date: 09/24/2025
Date Signed: 09/24/2025 01:27:24 PM

Document Has Been Signed on 09/24/2025 01:27 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,URENA		FACILITY TYPE:	735
ADDRESS:	545 BISCAYNE CT		TELEPHONE:	(408) 649-8537
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 6		CENSUS: 6	DATE:	09/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:35 AM
MET WITH:	Aida Urena		TIME VISIT/ INSPECTION COMPLETED:	01:30 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) Christine Kabariti arrived unannounced to conduct the facility's required 1 - year annual inspection. LPA met with Administrator (ADM), Aida Urena. LPA arrived to the facility at 08:35am - 10:00am. Due to a Department meeting, LPA left the facility at 10:00am and returned at 11:30pm to continue the inspection. During visit, LPA toured the facility with staff to include the resident bedrooms, bathrooms, living room, kitchen, garage, and backyard. The shed in the backyard observed with storage items. There were 2 staff present to 2 residents during visit. 2 staff present are fingerprint cleared and associated to the facility. All fire exit routes are free and clear of obstruction. Fire extinguisher purchased on 08/25/2025. Carbon monoxide present and observed operable. Facility temperature maintained at 74 degrees F. At 08:45AM, LPA measured the hot water temperature in the hallway bathroom which measured at 104.2 degrees F. The hot water was also measured in the resident's shared bedroom located next to the hallway bathroom, which measured at 102 degrees F. At 11:57AM, LPA measured the hot water in the hallway bathroom again which measured at 100.7 degrees F. A type A deficiency was cited today per Title 22 Section 80088(e)(1) based on the hot water temperature being measured below 105 degrees F. Resident bedrooms equipped with beds, linens, dressers, and adequate lighting. Bathrooms equipped hygiene items. Sharp objects observed locked. It was observed that one of the bathrooms located in the shared resident bedroom near the second floor office area was currently under construction. ADM states the shower tiles are currently getting fixed because the tile were cracked. The residents in that bedroom are both ambulatory are currently using the shower located on the second floor while the shower tiles are under construction. SEE LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025

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: SHIRAN CARE MANAGEMENT INC.	FACILITY NUMBER: 435202816
	VISIT DATE: 09/24/2025

NARRATIVE

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Kitchen equipped with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 50 degrees F. Freezer temperature maintained at 8 degrees F. ADM stated that the freezer and refrigerator temperature may be increased because they have a resident who opens and closes the refrigerator and freezer constantly throughout the day. LPA observed the items inside the freezer are frozen and refrigerator items are cold. LPA Kabariti did observe the resident constantly open and close the refrigerator and freezer throughout visit. LPA suggested to monitor and log the refrigerator/freezer temperature daily possibly during the NOC shift while resident's are asleep. ADM agreed and stated to communicate this procedure with staff and to implement a temperature log for staff to fill out daily.

Facility has emergency go bags located next to the front entrance. LPA observed the facility has emergency lighting and first aid kits. Disaster drills are being completed quarterly and the last drills were completed in January, February, June and July 2025.

LPA reviewed 3 resident records. Resident records contains an admission agreement, medical assessment, TB result, appraisal/needs and services plan, consent forms, and personal rights. 3 resident's centrally stored medications and centrally stored medication records were inspected and all medications were accounted for. LPA observed the centrally stored medications records were not complete as some of the medications did not include the start date of the when the medication was started. LPA recommended the Administrator to ensure the centrally stored medication records are complete to include (but not limited to) the start date of when the medications are started. 2 out of 3 residents P&I money was inspected.

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.

Documents were requested to update the facility file: lease agreement, LIC308, LIC610D, administrator certificate by 09/26/2025.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Aida Urena and a copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2025 01:27 PM - It Cannot Be Edited

Created By: Christine Kabariti On 09/24/2025 at 12:17 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: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, 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, the licensee did not comply with the section cited above in wherein the hot water tempature was measured between 100.7 - 104.2 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2025
	Plan of Correction
1 2 3 4	Administrator states they will adjust the hot water temperature today and implement a hot water log for staff to fill out. Administrator will submit proof of the hot water temperature to LPA Kabariti via email by POC due date.

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.

	Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:

	Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025

LIC809 (FAS) - (06/04)

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