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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202823
Report Date: 02/04/2025
Date Signed: 02/04/2025 03:39:41 PM

Document Has Been Signed on 02/04/2025 03:39 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:APOLLO ADULT DAY PROGRAMFACILITY NUMBER:
435202823
ADMINISTRATOR/
DIRECTOR:		LAUREL, PATRICK M.FACILITY TYPE:
775
ADDRESS:888 CAPITOL AVETELEPHONE:
(408) 439-2636
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 150CENSUS: 150DATE:
02/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Patrick LaurelTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Administrator (ADM) Patrick Laurel.

The purpose of today's visit is to follow up with the incident report that Community Care Licensing (CCL) office received on 01/29/2025. On 01/28/2025, around 9:50AM, Client C1 was found missing in the Day Program facility. Facility staff went out to search for C1. C1 was found by the facility staff S1, S2 and S3 around 10:35AM at Calvary Catholic Cemetery. The distance between the day program and Calvary Catholic Cemetery is around 1.7 miles per google map. C1 was assessed and found without any injury.

LPA interviewed Administrator (ADM). ADM stated C1's primary care staff S4 was late at the Day Program on 01/28/2025, and the facility assigned alternative care staff S5 to supervise C1. S5 was not familiar with C1's behavior. ADM stated C1 requested to use restroom, S5 was not waiting outside the restroom for C1 to finish using restroom. ADM stated C1 was found missing in the facility around 9:50AM. ADM stated the facility conducted a staff training of supervision and elopement on 1/28/2025.

Based on the reviewed of C1's Appraisal Needs and Service plan (ANS) dated on 01/09/2025, C1 has history of elopement, and needs daily frequent tracking.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D.
An immediate civil penalty of $500.00 is being assessed today for violation the absence of supervision.

Exit interviewed was conducted with ADM. The report was provided to ADM for review and signature. Appeal rights was provided. A copy of the report was provide to ADM.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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Document Has Been Signed on 02/04/2025 03:39 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 02/02/2025 at 12:53 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: APOLLO ADULT DAY PROGRAM
FACILITY NUMBER: 435202823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/05/2025
Section Cited
CCR
82078(a)

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82078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement.

This requirement is not met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and staff training to ensure clients are provided care and supervision necessary to meet the client's needs by POC due date.
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Based on the interview and records reviewed, on 1/28/25, C1 left the facility without staff knowledge. C1 was found later at cemetery about 1/7 miles from the facility. This poses/posed an immediate Health, Safety Rights risk to persons in care.
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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: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
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