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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202824
Report Date: 10/29/2024
Date Signed: 10/29/2024 10:25:17 AM

Document Has Been Signed on 10/29/2024 10:25 AM - 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:LYRIC LODGEFACILITY NUMBER:
435202824
ADMINISTRATOR/
DIRECTOR:		HAYES, JEFFREYFACILITY TYPE:
735
ADDRESS:1306 VINCI PARK WAYTELEPHONE:
(669) 284-8920
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Jeffrey Hayes AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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Licensing Program Analyst (LPAs) Marcela Yanez and Manuel Monter conducted an unannounced Required 1 Year visit and met with Jeffrey Hayes, Administrator.

During visit, LPAs toured the facility inside and out. LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. ADM tested the carbon monoxide detectors in the hallway and is functioning. LPA toured two out of two bathrooms. Each bathroom had available soap and paper towels and functioning lights. LPA's measured with thermometer facility water in Bathroom #1 measured at 119.4 degrees F.

LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies.
LPAs observed a container of "fabuloso" on the floor in the laundry room, accessible to residents in care. (Photograph was taken.)

LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days.

While touring the backyard, LPA's observed a storage unit that was unlocked an accessible to residents, The storage unit had, paint cans. (Photographs were taken.) ADM stated he is going to buy a pad lock and stated he has never been told the shed needed to be locked.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: LYRIC LODGE
FACILITY NUMBER: 435202824
VISIT DATE: 10/29/2024
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LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 08/2024. LPA reviewed Fire and Earthquake log was last conducted on 08/05/2024.

LPA reviewed resident records for 3 residents. LPA reviewed 3 staff records.

A deficiency was cited as per California Code of Regulations Title 22. This report was reviewed with Jeffrey Hayes and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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Document Has Been Signed on 10/29/2024 10:25 AM - It Cannot Be Edited


Created By: Marcela Yanez On 10/29/2024 at 09:55 AM
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: LYRIC LODGE
FACILITY NUMBER: 435202824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2024
Section Cited

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80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidence by:
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Based on observation a shed in the backyard was found unlocked and contained paint cans, accessible to residents in in care. LPAs also observed in laundry area a bottle of Fabuloso accessible as well. This poses a health, safety-personal rights risk to resident in care.
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ADM stated he will submit a POC date by 10/30/2024

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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:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


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