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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202906
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:01:48 PM

Document Has Been Signed on 11/21/2024 12:01 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:SPENCER ADULT CARE HOMEFACILITY NUMBER:
435202906
ADMINISTRATOR/
DIRECTOR:
TEODORO, ANELISEFACILITY TYPE:
735
ADDRESS:9055 SPENCER CTTELEPHONE:
(408) 393-8075
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Anelise TeodoroTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Administrator, Anelise Teodoro.

During visit, LPA toured the facility to include the living rooms, kitchen, 3 resident bedrooms, 1 staff bedroom, bathroom, laundry room, garage and backyard. All fire exit routes were free and clear of obstruction. No residents observed present as all residents were at school. 3 live-in staff present who are fingerprint cleared and associated to the facility. The facility was granted 3 underage exceptions in October 2023 by the Department. As of today, all residents in this home are over the age of 18.

Facility temperature maintained at 68 degrees F. Carbon monoxide detector in the hallway observed operable. Fire extinguisher was purchased on 05/03/2024. Sharp objects, chemicals, disinfectants, and medications observed locked. Kitchen refrigerator maintained at 39.7 degrees F. Freezer temperature initially maintained at 3 degrees F. LPA moved the thermometer to another section of the freezer, which read to 13 degrees F. The Administrator moved the thermometer to another area and adjusted the setting of the freezer. The final reading of the freezer temperature was -2 degrees F. LPA observed the items inside the freezer were frozen. Bathroom hot water temperature maintained at 113.9 degrees F. In the garage, LPA observed a large quantity of black spots resembling black mold along the wall and door leading out into the backyard. Administrator did not know what the block spots were but will contact their maintenance personnel to check what the black spots are. Photographs using LPAs state provided cellphone were obtained. There are no food items and resident clothing that was exposed in the garage. The garage is equipped with 1 refrigerator and boxes. Administrator states the residents do not utilize the garage. See LIC809-C for additional information.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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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: SPENCER ADULT CARE HOME
FACILITY NUMBER: 435202906
VISIT DATE: 11/21/2024
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Resident bedrooms observed well-kept. Each bedroom contains a bed for each resident, linens, night stand, and closet. The sliding doors were able to easily open. There is a curtain on the sliding door and windows for privacy. The bedroom doors has locks on the door handle, however, LPA observed staff can easily unlock the door from the outside by twisting the button.

3 resident files were reviewed and observed with an admission agreement, up-to-date appraisal/needs and services plan, IPP, medical assessment, TB result, safeguard of personal properties and valuables, personal rights and consent form. 3 out of 3 residents centrally stored medication and records were reviewed and observed maintained with no issues noted. 3 out of 3 resident's P&I money was inspected and observed maintained with all money accounted for.

3 staff files were reviewed to include fingerprint clearance, 1st Aid certification, health screening, job application, and annual training. LPA observed 2 out of 3 staff member's TB result. 1 out of 3 staff members showed a positive TB test on the health screening form, however, the final result of the further testing was not included in the file. During visit, staff found that the final result of the staff's TB is in a CD, which the Administrator was unable to access. Administrator states to have access to a CD player in a separate location and the Administrator will send the final result of the TB result to LPA Dolores before end of day.

Facility has an infection control plan. PPE supplies to include gloves observed. Facility has an emergency disaster plan. Emergency drills are being conducted quarterly. Each resident has a grab and go backpack filled with extra clothes, hygiene supplies, mini flashlight, non-perishable foods, first aid kit, and an emergency form. LPA observed the non-perishable foods in 1 out of 6 backpacks was expired. Administrator disposed of the non-perishable foods. LPA advised Administrator to check all grab and go backpacks to ensure all the non-perishable foods are not expired. The facility is only equipped with the mini flashlights in each resident's grab and go backpack. Administrator states a plan to purchase another back-up lighting in case of a power outage / emergency. Advisory note provided.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Anelise Teodoro and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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