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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202864
Report Date: 05/22/2024
Date Signed: 05/22/2024 11:17:55 AM

Document Has Been Signed on 05/22/2024 11:17 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:IFUR'S CARE HOMEFACILITY NUMBER:
435202864
ADMINISTRATOR/
DIRECTOR:		MENDINUETO, VERONICAFACILITY TYPE:
735
ADDRESS:2861 LONGACRE COURTTELEPHONE:
(408) 613-2786
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Ifur Batong - Administrator TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 05/22/2024 at 8:00 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived and conducted an unannounced required 1 year inspection visit. LPA was greeted by 1 staff and the administrator (ADM) Ifur Batong. LPA stated the purpose of the visit to ADM.

The facility is a Adult Residential Facility (ARF) licensed to serve ages 18 through 59. Facility currently serves 5 ambulatory and 1 non- ambulatory residents that are developmentally disabled. 2 staff were present at the time of the visit. 5 out 6 residents are attending day program. 1 out of 6 was present at the facility waiting to be taken to his/her doctor's appointment.

At 8:10 a.m. LPA toured the facility inside and outside with ADM, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, 2nd floor rooms, backyard and walkways. The temperature inside the home was at 68 to 69.8 degrees F.

LPA and ADM toured the 5 rooms, 3 out of the 5 room are located at ground floor, and 2 are located on the 2nd floor. LPA observed 3 bathroom, 2 on the ground floor and one on the 2nd floor. ADM stated no staff sleeps in the facility. The facility has a NOC (nocturnal) shift staff. LPA observed 3 rooms on the ground floor are shared rooms. LPA observed rooms to be organized, sanitary and free from any debris and has sufficient storage for residents' personal belongings. LPA observed that 3 out 3 ground floor bedroom has sliding door that easily opens and are free from obstruction.

LPA observed that the facility has smoke and carbon monoxide alarm system that was tested by the staff and found to be in good working condition. Hallways are free from obstruction. LPA observed ramps and walkways are free from obstruction. LPA observed the backyard area to be free from debris and is maintained.


see LIC 809C for page 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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
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: IFUR'S CARE HOME
FACILITY NUMBER: 435202864
VISIT DATE: 05/22/2024
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LPA with ADM toured 2 full bathrooms on the ground floor to have anti skid mats and grab bars and with sufficient supply of paper towels and toiletries. LPA with ADM inspected the 2nd floor rooms and found the rooms are utilized as a storage and office area and not accessible to residents. ADM stated the gate was placed at the bottom of the stairs to prevent residents from going up and down the stairs that may cause accident.

LPA tested the water temperature for kitchen and bathrooms, water temperature measured at 112 degrees F to 114 degree F. Dining and kitchen area and living room area were observed to be sanitary and organized. The facility has sufficient supply of perishable food for 2 days and non-perishable food for 7 days. The fire extinguishers was inspected on 12/4/2023. LPA observed knives are in a locked drawer not accessible to residents.

LPA and ADM inspected the laundry area. LPA observed the laundry area is located inside the garage and are in good working condition. Cleaning supplies and detergents were separated and in a locked cabinet. LPA observed the medication cabinet is locked and is not easily accessible. LPA observed first aid kit to be complete and easily accessible.

LPA reviewed facility record, 3 staff record and 3 out of 6 resident record. Facility's fire drill training conducted on 4/27/2024. The facility records are up to date. Staff training records were up to date. Staff records were reviewed with current first aid certifications, clearance and training. Residents files were reviewed to be complete. Residents' medications are labeled and current.

LPA Requested for the update of the following: Surety Bond, LIC 500, LIC 308, Emergency Disaster Plan & resident roster.

No Deficiencies are cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with ADM Ifur Batong, a copy of the report was provided.

end of report
page 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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