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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202874
Report Date: 10/17/2024
Date Signed: 10/17/2024 03:10:07 PM

Document Has Been Signed on 10/17/2024 03:10 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MORNINGSTAR MEMORY CARE AT SAN TOMASFACILITY NUMBER:
435202874
ADMINISTRATOR/
DIRECTOR:		PADILLA SANCHEZ, KENIAFACILITY TYPE:
740
ADDRESS:3930 WILLIAMS RDTELEPHONE:
(669) 201-2015
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 82CENSUS: 28DATE:
10/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Kenia SanchezTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Santino Fortes arrived to the facility unannounced to open the initial complaint investigation for complaint control number 26-AS-20241007160553. During tour of the facility, a violation was observed, therefore prompting a case management – other visit. LPAs met with Executive Director, Kenia Sanchez.

During the tour of the facility, LPAs observed 2 out of 2 side exit gates located in the patio were locked using a combination lock. 2 out of 2 side gates are considered an emergency exit area. ED states the locks were implemented when ED started at the facility about 3 months ago. ED was unable to produce documentation to show a fire clearance approval to lock the exterior fence gates.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Executive Director, Kenia Sanchez and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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 10/17/2024 03:10 PM - It Cannot Be Edited


Created By: Christine Dolores On 10/17/2024 at 02:19 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: MORNINGSTAR MEMORY CARE AT SAN TOMAS
FACILITY NUMBER: 435202874

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2024
Section Cited
CCR
87705(l)(2)

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(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by:
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Licensee will remove the combination locks on the 2 side gates in the patio area and will replace the locks for a door alarm.
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Based on interview, record review and observation the licensee did not comply with the section cited wherein 2 out of 2 side gates in the patio were observed locked using a combination lock which poses an immediate health, safety, and personal rights risk to persons in care.
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Licensee will submit a picture of the 2 side gates and email communication regarding resolving the locks to the side gates to LPA Dolores via email by POC due date of 10/18/2024.

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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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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