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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202862
Report Date: 07/09/2026
Date Signed: 07/14/2026 07:43:00 AM

Document Has Been Signed on 07/14/2026 07:43 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:HANSELL VILLAFACILITY NUMBER:
435202862
ADMINISTRATOR/
DIRECTOR:		ELIZABETH BAUTISTAFACILITY TYPE:
740
ADDRESS:5343 HANSELL DRIVETELEPHONE:
(408) 362-9195
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
07/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Elizabeth BautistaTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual required inspection and met with administrator (ADM) Elizabeth Bautista and stated the purpose of the visit.

The facility is licensed to serve adults 60 and over; approved for 6 non-ambulatory, 1 maybe bedridden in room #2 and hospice waiver for 4. LPA observed residents and staff present, 6 out 6 residents were in their room resting. 5 out of 6 are non-ambulatory and 1 out of 6 is ambulatory.

LPA toured the facility, including common areas, resident rooms, kitchen, bathrooms, driveway, and outdoor spaces and storage areas. Indoor temperature was within acceptable range of 70°F. The kitchen was sanitary and organized; knives and chemicals were locked. Food supply met requirements (2 days perishable, 7 days non-perishable). Kitchen water temperature measured at 123.1°F. Bathroom water temperature measured at 120°F. A technical assistance was provided to ADM for the kitchen hot water temperature. LPA inspected the refrigerator and the temperature gauge inside the refrigerator reads at 40° F. The freezer temperature is at 0°F.

Medications were locked and inaccessible to residents. However, staff has pre-poured medication in an unlocked drawer for each resident to be given at a later time of the day. LPA observed medication were in a clear covered plastic container with residents name and AM/PM schedule.

LPA inspected the interior of the facility and observed the following. The facility has a total of 4 bedrooms, 2 out of 4 bedroom are single occupancy and 2 out of 4 are shared. Bathrooms had grab bars and non-skid mats. Resident's have storage that are sufficient to store personal items. page 1 of 2
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2026
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 9
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: HANSELL VILLA
FACILITY NUMBER: 435202862
VISIT DATE: 07/09/2026
NARRATIVE
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LPA observed that all residents were using hospital beds with half bed rails. LPA observed wheelchairs parked in the living room area for resident's use. The walkways and hallways were free from obstruction and tripping hazard. LPA observed that 2 out of 6 resident (R1 and R3) uses indwelling urinary catheters. ADM stated that R1 is visited by a home health care nurse once every two weeks and R3 is checked at the hospital. ADM stated that staff empties R1 and R3s urine collector bag. Based on interview zero out of the six resident are receiving hospice care and zero out of the six residents are bedridden.

LPA inspected the exterior of the facility and observed the following: An unused mattress and metal bedding leaning on the wall by room #3 that obstructed the walkway when exiting and turning right from room #3. A low hanging tree branch was obstructing the pathway towards the walkway. The living room has a sliding door that directly access the tomato patch garden. The sliding door in the living room when opened was stuck and not easily opened. The screen sliding door from Room #2 was not aligned and hangs sideways.

LPA reviewed 6 resident and 4 staff records, including medication logs, admission agreements, care plans, personal and incidentals, health screenings, and training. 4 out of 4 staff have required clearances and certifications and training, however, 4 out of 4 staff record of training did not have a date when it was provided. A technical assistance was provided to ADM.

Based on record review R1 and R6 were diagnosed with dementia. R1 and R6s medical assessment (LIC 602) was dated October 2023. Based on record review R1 and R6 appraisal needs and services plan (LIC 625) was dated January 2025, and missing the resident or their responsible party's signature.

The facility conducts fire and earthquake drill quarterly for each shift. Last drill practice training was conducted on different dates and times of January 2026. The facility is equipped with panel fire alarm system and a fire extinguisher inspected on 05/21/2026.

Deficiencies are being cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with ADM Elizabeth Bautista. A copy of the report and appeals rights was provided.

end of report
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/14/2026 07:43 AM - It Cannot Be Edited


Created By: Maria Partoza On 07/09/2026 at 01:15 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: HANSELL VILLA
FACILITY NUMBER: 435202862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based observation the licensee did not comply with the section cited above by not ensuring that sliding door in the living room is operational and easily accessible in case of emergency and the sliding screen door in room #2 is in good repair and does not pose a hazard to individual using the exit doorway, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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ADM stated that he/she will have a written plan of correction or a memorandum of understanding to address the maintenance of the exit doors, and screen door of the facility by the POC due date of 07/10/2026.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, an unused mattress by the side of room #3 sliding door, a low hanging tree branch and a patch of tomato garden directly obstructs the pathways to walkways which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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ADM stated he/she will submit a written plan of correction or a memorandum of understanding to address the unused mattress, the low haning tree branch and the patch of tomato garden that directly obstructs pathways and walkways by the POC due date of 07/10/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/14/2026 07:43 AM - It Cannot Be Edited


Created By: Maria Partoza On 07/09/2026 at 01:16 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: HANSELL VILLA
FACILITY NUMBER: 435202862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by not ensuring that medications were stored in their original containers & not accessible to resident. Medications were observed in a clear covered container labeled with the resident's name for AM and PM. ADM stated that the medication are pre-poured for the entire day and transferred from its original container which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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ADM stated he/she will submit a written plan of correction or memorandum of understanding to address the medication and ensure that the medications are not pre-poured or pre-prepared and medications are locked and not accessible to residents in care. Written plan of correction will be submitted to LPA by the POC due date of 7/10/2026.
Type A
Section Cited
CCR
87623(a)(1)
87623 Indwelling Urinary Catheter (a)The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: (1)If the resident is physically and mentally capable of caring for all aspects of the condition except insertion and irrigation. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not ensure a resident with a restricted health condition met the criteria for retention. R1 and R3 was observed with an indwelling urinary catheter. R1 and R3 are incapabe of self-care. Licensee did not submit a written exception request for a Restricted Health Condition Care Plan to the Department and is retaining 2 out of 6 residents with a prohibited health condition, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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ADM stated he/she will send a written plan of correction or memorandum of understanding to address the Restricted Health Condition Care Plan for the indwelling urinary catheter for R1 and R3 and will submit the necessary request for exception on or before the POC due date of 07/10/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/14/2026 07:43 AM - It Cannot Be Edited


Created By: Maria Partoza On 07/09/2026 at 02:07 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: HANSELL VILLA
FACILITY NUMBER: 435202862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
87463 Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above by not requesting an annual routine visit with a licensed professional once every twelve months for 2 out 6 residents (R5 and R6). R5 and R6s medical assessment (LIC 602)was dated October 2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2026
Plan of Correction
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ADM stated he/she will submt a written plan of correction or memorandum of understanding to address the medical assessment (LIC 602) of R5 and R6 and schedule a visit with the physician on an annual basis for all residents in care. ADM will submit the plan of correction on or before 07/23/2026.
Type B
Section Cited
HSC
87463(a)
87463Reappraisals (a)The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months...This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above by not ensuring that R5 and R6's appraisal needs and services plan are updated based as frequently as necessary. Based on record review R5 & R6 were diagnosed with dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
- CCR 87463(a) is the correct violation code.
POC Due Date: 07/23/2026
Plan of Correction
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ADM stated he/she will submit a written plan of correction or memorandum of understanding to address and update the appraisal needs and services plan as frequently as necessary or once every 12 month by the POC due date of 07/23/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 07/14/2026 07:43 AM - It Cannot Be Edited


Created By: Maria Partoza On 07/09/2026 at 02:35 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: HANSELL VILLA
FACILITY NUMBER: 435202862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(1)(2)
87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1)(2) (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review and interview, ADM did not ensure tha his/her mandated duty to manage and administer the facility in compliance with applicable laws and regulations were met. The 4 Type A and 2 Type B violations that was cited today for the indwelling catheters and un-updated dementia care plan are, non-compliant operational oversight demonstrates that the Administrator did not conform to the requirements of Chapter 8 of Title 22, directly impacting residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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ADM stated he/she will submit a written plan of correction or a memorandum of understanding that addresses the qualification of the ADM to ensure he/she manages, administer the applicable laws and regulation are met. ADM stated he/she will submit the plan of correction on or before the due date of 07/10/2026.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
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