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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202867
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:31:15 PM

Document Has Been Signed on 06/22/2023 04:31 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:WARNER HOME #2FACILITY NUMBER:
435202867
ADMINISTRATOR:GALLEON, ARMANDFACILITY TYPE:
735
ADDRESS:3068 FLORENCE AVE.TELEPHONE:
(831) 917-2870
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Pam SloanTIME COMPLETED:
04:24 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted a unannounced annual inspection visit and met with Licensee Pam Sloan (LNS) and administrator (ADM) Armand Galleon.

LPAs checked 5 resident record files (R1 - R5) and 5 staff record files (S1 - S5).

LPA toured the facility inside out with LNS. LPA inspected living room, kitchen, dinning area, and laundry room. Medication closet, knives closet, and cleaning product closet were observed locked.

There are 3 shared resident rooms at first floor for residents, and 2 restrooms at first floor. There is 1 staff live-in rooms in the first floor and 1 staff live-in room at the second floor in facility. One office was observed at the facility. Room temperature was observed at 70 degree F, and hot water temperature was observed at 110 degree F. The temperature of refrigerator was observed at 40 degree F, and the temperature of the freezer was observed at 0 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm system. LNS tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 06/14/2023. LPA inspected the backyard, there was no obstruction to block the walkway. There is a detached garage at the facility.

Exit interview was conducted with LNS. LIC9099-D and Appeal Rights were attached. The reports were provided to LNS for signature. A copy of this report was provided to LNS.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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Document Has Been Signed on 06/22/2023 04:31 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 06/22/2023 at 03:08 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: WARNER HOME #2
FACILITY NUMBER: 435202867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility did not have nigh light in the hallway, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2023
Plan of Correction
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Licensee agreed to submit a Plan of Correction by the due date to put a night light in the hallway.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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