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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202867
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:37:42 PM

Document Has Been Signed on 06/20/2024 04:37 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/
DIRECTOR:		GALLEON, ARMANDFACILITY TYPE:
735
ADDRESS:3068 FLORENCE AVE.TELEPHONE:
(831) 917-2870
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 6DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:56 PM
MET WITH:Pam SloanTIME VISIT/
INSPECTION COMPLETED:
04:30 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 House manager (HM) Teresita Dela Pena.

LPAs checked 3 resident record files and 3 staff record files.

LPA observed 3 residents and 3 staff in the facility.

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 office in the first floor and 1 staff live-in room at the second floor in facility. Room temperature was observed at 72 degree F, and hot water temperature was observed at 114 degree F. The temperature of refrigerator was observed at 30 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. First aid box, flash lights, and night light were observed in the facility. The last time the facility conducted the emergency drill is 6/2/2024.

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 05/31/2024. LPA inspected the backyard, there was no obstruction to block the walkway. There is a detached garage at the backyard which was used as staff room.

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: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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 06/20/2024 04:37 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 06/20/2024 at 03:07 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: WARNER HOME #2
FACILITY NUMBER: 435202867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80086(a)
Alternations to Existing Building or New Facility (a) Prior to construction or alterations, all licensees shall notify the licnesing agency of the proposed change.

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 in that the detached garage was used as a staff room which poses an immediate health, safety or personal rights risk.
POC Due Date: 06/21/2024
Plan of Correction
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Licensee agreed and understood the importance of notifying CCL office of any change of use to the facility. Licensee agreed to submit a plan of correction by the POC due date.
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: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
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