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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202910
Report Date: 12/21/2024
Date Signed: 12/21/2024 04:08:51 PM

Document Has Been Signed on 12/21/2024 04:08 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:MANFRED CARE HOME LLCFACILITY NUMBER:
435202910
ADMINISTRATOR/
DIRECTOR:		DUMANTAY, MADONNAFACILITY TYPE:
735
ADDRESS:2389 RENFIELD WAYTELEPHONE:
(408) 818-0134
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
12/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Administrator Madonna DumantayTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst LPA Marcela Yanez met with Administrator Madonna Dumantay During the visit, LPA observed 5 residents and 4 staff. LPA explained the purpose of the visit. the facility is approved for age range 18 through 59. Approved for four (4) ambulatory and two (2) non ambulatory in room 4.

LPA toured the facility inside out with ADM which included the Living room, kitchen, refrigerator temperature measured 39 degrees F and freezer measured at 0 Degrees F, dining room, 2 restrooms that had grab bars and non skid mats and 3 residents bedrooms.

While touring the facility LPA observed 5 of 6 residents in activity room and living room listening to Christmas music and watching Television. 1 resident is in skilled nursing facility.

During inspection LPA observed two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 111.3 degrees F in resident bathroom #1 and bathroom #2 at 108.1 degrees F.

The staff bedroom was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways and ramp.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2024
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: MANFRED CARE HOME LLC
FACILITY NUMBER: 435202910
VISIT DATE: 12/21/2024
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2 Fire extinguisher one located in kitchen and 1 in the hallway next to across from staff room was purchased in 11/12/2024 The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 10/13/2024 for fire drill and for earthquake on 10/03/2024
During inspection LPA observed a bottle of rubbing alcohol and Hydrogen peroxide in resident bedroom #4, ADM put the toxic in locked cabinet.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA interviewed 2 staff and 1 resident

Deficiencies cited during today's visit (see 809-D) This report was reviewed with Administrator Madonna Dumantay and a copy of the signed report was provided and a copy of Appeals Rights were provided.

End of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2024 04:08 PM - It Cannot Be Edited


Created By: Marcela Yanez On 12/21/2024 at 03:47 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: MANFRED CARE HOME LLC
FACILITY NUMBER: 435202910

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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, interview and record review, the licensee did not comply with the section cited above by storing a bottle of Rubbing Alcohol and a bottle of Hydrogen Peroxide in resident bedroom #4 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee will complete an inservice for staff. Letter of understanding will be submitted by poc date 12/22/2024
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 Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2024


LIC809 (FAS) - (06/04)
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