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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202826
Report Date: 01/20/2023
Date Signed: 01/20/2023 01:31:28 PM

Document Has Been Signed on 01/20/2023 01:31 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:LOUPE ADULT RESIDENTIAL FACILITY INC.FACILITY NUMBER:
435202826
ADMINISTRATOR:VALENZUELA, JALANOFACILITY TYPE:
735
ADDRESS:1257 LOUPE AVENUETELEPHONE:
(408) 620-1254
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 4CENSUS: 4DATE:
01/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Cecilia Valenzuela, Co- AdministratorTIME COMPLETED:
01:40 PM
NARRATIVE
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On 1/20/2023 at 9:11am, Licensing Program Analyst (LPA) Simi Rai with LPA Manuel Monter and Licensing Program Manager (LPM) Romeo Manzano conducted a Case Management visit and met with Co- Administrator Cecilia Valenzuela. The administrator, Jalano Valenzuela is on vacation and Cecilia Valenzuela is co-administrator and designated administrator. LPAs and LPMs spoke to Administrator on the phone as well.

The purpose of today's visit was related to an eviction notice for resident (R1) to obtain additional information.
There were no clients observed at the facility and the clients were attending day programs. LPA observed 3 staff at the facility. LPAs and LPM conducted staff interview and record reviews. Copies of R1's facility records such as but not limited to 1st Quarterly Report 11/18/2022, Behavior Support Plan 10/17/2022, and Appraisal/ Needs and Services.

Based on record review, R1 was admitted to the facility on 6/10/2022. LPA Rai reviewed Individual Program Plan (IPP) for R1 dated 11/4/2021 with IPP tentative scheduled for update on 7/31/2022. Per Administrator (ADM), Jalano Valenzuela, stated scheduled IPP for 7/31/2022 was not conducted with San Andreas Regional Center. ADM did not update R1's Appraisal/Need and Services as planned to address resident's continued behavior of suicide idealization.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

Technical Violation Note was provided as well.

This report was reviewed with Co- Administrator, Cecilia Valenzuela. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/20/2023 01:31 PM - It Cannot Be Edited


Created By: Simranjit Rai On 01/20/2023 at 11:32 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: LOUPE ADULT RESIDENTIAL FACILITY INC.
FACILITY NUMBER: 435202826

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2023
Section Cited
CCR
85068.1(a)

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Admission Procedure (a) The licensee shall develop, maintain, and implement admission procedures which shall meet the requirements specified in this section.

This requirement is not met as evidenced by:
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According to Co-Administrator will inform Administrator to complete an updated Appraisal/Needs and Services Plan and email LPA Rai on 1/25/2023.
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Based on interviews and record review, the Appraisal/ Needs and Services Plan of R1 was created 5/22/2022, but Administrator did not update Appraisal to address resident's continued sucide idealization behaviors which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
01/27/2023
Section Cited
CCR80065(f)(3)

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Personnel Requirements (f)(3) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas ...and as evidenced by safe and effective job performance.
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According to Co-Administrator will inform Administrator to train staff on suicidal ideations and related behaviors. Administrator to submit evidence of staff training logs and training information (name of trainee and trainer, topic and time) through email LPA Rai on 1/27/2023.
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Based on interviews with Staff (S1 & S2) and record review, the co-Administrator was not able to produce training logs to show staff record of training on addressing R1's behavior, which poses a potential Health, Safety, or Personal 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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023


LIC809 (FAS) - (06/04)
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