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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202906
Report Date: 02/06/2024
Date Signed: 02/06/2024 11:59:43 AM

Document Has Been Signed on 02/06/2024 11:59 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:SPENCER ADULT CARE HOMEFACILITY NUMBER:
435202906
ADMINISTRATOR:TEODORO, ANELISEFACILITY TYPE:
735
ADDRESS:9055 SPENCER CTTELEPHONE:
(408) 393-8075
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
02/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Anelise TeodoroTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – deficiencies visit due to a violation observed during a complaint investigation (Control Number: 26-AS-20231218105909). LPA met with Administrator, Anelise Teodoro.

Based on record review, the facility transitioned from a Children’s Residential Facility into an Adult Residential Facility. On 11/16/2023, the facility was printed their new license.

During LPA Dolores’s visit on 12/27/2023, it was found that all staffs criminal record clearances were not transferred from the previous facility to the new facility license, therefore, majority of the staff were not associated to the facility.

Based on interview, the Administrator was unable to transfer personnel through the Department’s background check system because the Administrator was not yet granted access to the Department’s background check system since they transitioned into an Adult Residential Facility. Documents show the Administrator had sent a request to grant access to the Department’s background check system on 12/22/2023. Based on interview, the Administrator did not send the Department any criminal record transfer forms to transfer personnel manually in the Department’s system. The criminal record transfer request were sent to the Department after 12/27/2023.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Anelise Teodoro and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2024
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 02/06/2024 11:59 AM - It Cannot Be Edited


Created By: Christine Dolores On 02/06/2024 at 11:33 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: SPENCER ADULT CARE HOME
FACILITY NUMBER: 435202906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/13/2024
Section Cited
CCR
80064(a)(3)

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(a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement is not met as evidenced by:
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Licensee will have the Administrator re-take the Criminal Background Clearnace course that is part of the essenital CEU as a refresher. Licensee will submit the certificate of completion to LPA Dolores via email by POC due date.
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Based on interview, record review, and observation the Administrator did not submit all the staff criminal record clearance transfer forms after the facility received their new license which poses/posed a potential health, safety, and personal rights risk to persons in care.
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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: 02/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024


LIC809 (FAS) - (06/04)
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