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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202852
Report Date: 04/14/2023
Date Signed: 04/14/2023 10:57:59 AM

Document Has Been Signed on 04/14/2023 10:57 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:EMANUEL'S CARE HOMEFACILITY NUMBER:
435202852
ADMINISTRATOR:GONZALEZ, DORISFACILITY TYPE:
735
ADDRESS:2053 RADIO AVETELEPHONE:
(408) 592-5303
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 0DATE:
04/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
11:05 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Manuel Monter arrived unannounced to conduct a case management – deficiencies visit. LPAs met with Administrator, Doris Gonzalez and Manager, Esther Kattan.

On 01/24/2023, an investigator from the Department arrived at the facility to conduct an interview with staff (S1) regarding a complaint from a resident’s day program. Based on the interview, S1 has been living and working in the facility full-time for more than a year. Upon the investigators review of the Department's background check system, it appeared S1 was not fingerprint cleared and associated to the facility. During visit, LPA interviewed staff. Based on interview, S1 has a different last name. LPAs reviewed and obtained S1's live scan form and the Department of Justice fingerprint response, in which the date of birth matched with the individual in question. Based on review of Guardian, S1 is fingerprint cleared but is not associated to the facility. The facility was unable to produce the transfer request paperwork. Administrator and Manager was advised.

During visit, LPAs toured the facility to include the kitchen, living room, resident bedrooms, staff bedrooms, bathrooms, and backyard. No clients observed on site. Staff (S3) state 5 out of 5 clients are attending day program. LPAs observed staff (S2) inside the staff bedroom. Administrator states S2 "sometimes" sleeps in the facility. Administrator states S2 went to receive a live scan about twenty-three days ago but they have not received a background clearance. Manager states S2 started training on Wednesday, 04/12/23 and has slept in the facility for two days. S2 was asked to leave immediately. LPA Dolores informed Administrator that S2 cannot be living or working in a licensed care facility without obtaining a criminal record background clearance from the Department. Administrator and Manager understood. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
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: EMANUEL'S CARE HOME
FACILITY NUMBER: 435202852
VISIT DATE: 04/14/2023
NARRATIVE
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Additional Documents were obtained to include the facility's direct care staff schedule from 01/01/2023 - 04/02/2023.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S1 working and residing in the facility without association. Another civil penalty is being assessed for the amount of $200 ($100 per day x 2 days = $200) for S2 working and sleeping in the facility without receiving a criminal record background clearance. See LIC421BG.

Exit interview conducted with Administrator, Doris Gonzalez and Manager, Esther Kattan and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2023 10:57 AM - It Cannot Be Edited


Created By: Christine Dolores On 04/14/2023 at 10:29 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: EMANUEL'S CARE HOME
FACILITY NUMBER: 435202852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2023
Section Cited
CCR
80019(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or … This requirement is not met as evidenced by:
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Licensee will ensure S2 will not reside or work in the facility until S2 receives a criminal record clearance from the Department. S2 was immediately asked to leave.
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Based on interview, observation and record review S2 was working and sleeping in the facility without obtaining a criminal record background clearance which poses an immediate health, safety and personal rights risk to persons in care.
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Licensee will submit a statement of understanding to LPA Dolores by POC due date.
Type A
04/15/2023
Section Cited
CCR80019(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or ... This requirement is not met as evidenced by:
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Licensee will ensure to submit S1's transfer request form to the Department by today. Licensee will ensure all staff working and residing in the facility are associated to the facility.
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Based on interview, observation and record review S1 works and lives in the facility without association which poses an immediate health, safety and personal rights risk to persons in care.
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Licensee will review section 80019 and submit a statement of understanding to LPA Dolores by POC due date.
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: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023


LIC809 (FAS) - (06/04)
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