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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202885
Report Date: 03/18/2024
Date Signed: 03/19/2024 07:54:17 AM


Document Has Been Signed on 03/19/2024 07:54 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MERIDIAN VILLAFACILITY NUMBER:
435202885
ADMINISTRATOR:ROSANA MENDOZAFACILITY TYPE:
740
ADDRESS:2755 MERIDIAN AVETELEPHONE:
(408) 440-2445
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 5DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Rosana MendozaTIME COMPLETED:
12:58 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Steve Chang conducted an annual inspection visit, and met with administrator (ADM) Rosana Mendoza. 4 staff and 5 residents were observed in the facility. 3 resident files and 3 staff files were reviewed. 4 staff were associated with the facility.

License, Administrator Certificate, and personal rights posters were observed in the facility.

LPA toured the facility inside and out with ADM. LPA inspected family room, kitchen, dinning area, two restrooms, 4 bedrooms, and laundry room. Three resident shared bedrooms, one staff live-in room were observed. Medication closet was observed locked. Knives closet, and cleaning product cabinet were observed locked. Dish washing liquid was observed by the kitchen sink and unlocked. ADM put the dishing washing liquid in the cabinet under the sink and locked immediately.

First Aid Kit and flash lights were observed in the facility. Non-skid mats and Bars were observed in restrooms. Room temperature was observed at 73 degree F, and hot water temperature was observed at 110 degree F. The temperature of the refrigerator was at 40 degree F and the temperature of the freezer was at 0 degree F. Two day perishable food supplies and seven days nonperishable food supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm system. ADM tested the fire alarm and carbon monoxide detectors, and they were working fine. No night light was observed in the hallway. LPA inspected the backyard, there was no obstruction to block the walkway. A storage room was observed in the backyard. ADM tested the resident call button signal system and it works fine.
Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
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 03/19/2024 07:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: MERIDIAN VILLA
FACILITY NUMBER: 435202885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) 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 licensee did not comply with the section cited above in that there was no night lights in the hallway which poses/posed a potential safety risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due date. Administrator installed two night lights in the hallway immediately.
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 dish washing detergent was observed unlocked in the kitchen which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due date. Administrator locked the dish washing detergent immediately.
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 ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/19/2024 07:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: MERIDIAN VILLA
FACILITY NUMBER: 435202885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

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 a resident using oxygen equipment but there was no “No Smoking-Oxygen in Use” signs was observed in the facility which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due date to have the poster of “No Smoking-Oxygen in Use” signs to post in the facility.
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 ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3