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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202895
Report Date: 01/23/2026
Date Signed: 01/23/2026 11:11:24 AM

Document Has Been Signed on 01/23/2026 11:11 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:MORNINGSTAR ASSISTED LIVING OF WEST SAN JOSEFACILITY NUMBER:
435202895
ADMINISTRATOR/
DIRECTOR:		HIGGINS, JOLIEFACILITY TYPE:
740
ADDRESS:1380 S DEANZA BLVDTELEPHONE:
(669) 295-6500
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 149CENSUS: 87DATE:
01/23/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Wellness Director Trisa CysewskiTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation 26-AS-20250812163239. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Wellness Director (WD) Trisa Cysewski and explained the purpose of the visit.

The Department reviewed R1’s July and August 2025 Medication Administration Record (MAR). Based on a review, the facility is recording R1’s blood glucose level twice daily. The MAR is also tracking the change in glucose monitoring sensor every 2 weeks.

The Department reviewed R1’s Physician’s Order Report, dated December 13, 2025. Based on a review R1’s glucose monitoring is scheduled to be completed daily at 5:00am and 5:00pm. R1’s glucose sensor is changed every 2 weeks.

On January 8, 2026, LPA Manuel Monter interviewed Administrator (ADM) April Princesa. ADM stated R1’s family member changes R1’s censors every 2 weeks. ADM stated the med tech will provide the new censor to R1’ son and will observe the changing of the censors and will mark it on the MAR. ADM stated Medtech’s check the blood sugar for R1 by using the glucose monitoring device and check the blood sugar, via the censor.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: MORNINGSTAR ASSISTED LIVING OF WEST SAN JOSE
FACILITY NUMBER: 435202895
VISIT DATE: 01/23/2026
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On January 23, 2026, LPA interviewed Wellness Dirctor (WD) Trisa Cysewski. WD stated the facility can conduct a training with her medtechs she would send documentation showing her medtechs have been trained regarding R1’s glucose monitoring devices such as but not limited to: function, how the glucose censor is supposed to be changed, and interventions when the reading is out of normal ranges.

LPA advised WD the facility to update R1's service plan to address the care and supervision for his/her dialysis.

WD stated she will request a detailed physician order with parameters for the glucose monitoring device, such as who would change the sensor, and interventions when the reading is out of normal ranges.

The Department reviewed R1’s Individual Service Plan, dated November 1, 2025. The plan states under diabetes; R1 does not require blood glucose monitoring. Furthermore, the individual service plan does not state who would be changing R1’s glucose testing censor and evaluating the area for any adverse effects.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Wellness Dirctor (WD) Trisa Cysewski and a copy of the report and appeal rights were provided

Page 2 Out of 2. END OF REPORT
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2026 11:11 AM - It Cannot Be Edited


Created By: Manuel Monter On 01/23/2026 at 10:37 AM
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 ASSISTED LIVING OF WEST SAN JOSE
FACILITY NUMBER: 435202895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2026
Section Cited
CCR
87463(a)

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87463 Reappraisals (a) The pre-admission appraisal…shall be updated in writing as frequently as necessary…to keep the appraisal accurate…shall be referred to as the reappraisal.

This requirement was not met as evidence by:
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ADM stated she would send an updated individual service plan detailing how the facility will manage R1’s glucose monitoring requirements or how the glucose sensor will be replaced.
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Based on records reviewed, R1’s individual service plan does not address or explain how the facility will manage R1’s glucose monitoring requirements or how the glucose sensor will be replaced. This poses a potential health, safety or personal rights risk to persons in care.
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ADM stated the individual service plan will also indicate how to monitor the device and what interventions for out-of-ordinary range readings. ADM stated she will send the plan of correction to LPA by POC due date, January 30, 2026.

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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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2026


LIC809 (FAS) - (06/04)
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