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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202917
Report Date: 01/18/2024
Date Signed: 01/18/2024 10:47:20 AM

Document Has Been Signed on 01/18/2024 10:47 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:ELLIE REESE CARE HOME LLCFACILITY NUMBER:
435202917
ADMINISTRATOR:OVISO, PORTIAFACILITY TYPE:
735
ADDRESS:3175 SYLVAN DRTELEPHONE:
(408) 891-7016
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 0DATE:
01/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Applicant, Portia OvisoTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Simi Rai arrived announced to conduct the facility's pre-licensing visit. LPA met with Applicant (AP), Portia Oviso. There are no clients present on site.

The facility has one floor and has an approved fire clearance for 4 non ambulatory and 2 ambulatory residents. LPA Rai observed ramp in the backyard for bedroom exit for Bedroom 4 and Bedroom 3. AP stated the facility does not have staff rooms and staff will not be residing in the facility. AP stated the facility will have awake night staff. LPA Rai did not observe a telephone in the facility. AP will call the telephone company to set up a connection at the facilty.

LPA toured the facility inside and outside including the bedrooms, bathrooms, kitchen, dinning room and common areas. During the tour, LPA observed 1 out of 3 bedrooms were equipped with proper furniture and lighting. LPA observed 2 out of the 3 bedrooms being occupied at this time. AP stated AP's family members currently reside in the facility and will move out by Sunday, January 21st, 2024. The family members are not criminally background cleared.

Bathrooms are equipped with grab bars, nonskid floors, hygiene supplies, and toiletry. Facility kitchen is equipped with cups, plates, utensils, and cooking supplies. Hot water temperature was measured over 120 degrees Fahrenheit in Bathroom 2. The hot water in Bathroom 1 does not function where the hot water is not running but the cold water is functioning correctly. LPA Rai was not able to measure the hot water temperature due to the low hot water pressure.


Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ELLIE REESE CARE HOME LLC
FACILITY NUMBER: 435202917
VISIT DATE: 01/18/2024
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LPA observed 2 days of perishable food supplies. LPA observed a locked cabinet in the kitchen for sharps and chemical products. LPA Rai observed the facility's business license and facility sketch. AP will post the posters in the facility. The facility has designated locked medication cabinets. The fire extinguisher was purchased new on 8/23/2023.

COMP III was reviewed and completed with the Applicant.

The facility inspection on the following items were observed during today's visit which need to be addressed before the second pre-licensing visit:
1) posters to include the emergency telephone numbers, personal rights, CCLD compliant poster, complaint information, Rights of Resident Councils, Personal Rights of Residents in All Facilities.
2) 7 days of non-perishable food supply
3) first aid kit and battery operated flashlight
4) repair light bulb in the Bathroom 2
5) repair hot water pressure in the sink in Bathroom 1
6) maintain hot water temperature in both sinks in Bathroom 1 & 2 between 105-120 degrees Fahrenheit.
7) gardening tools inaccessible after use.
8) chemicals such as gasoline/propane and paint in the backyard inaccessible after use.
9) available telephone to use

Applicant will notify Licensing when the items above have been addressed.

LPA observed the facility is not ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB).This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Applicant, Portia Oviso and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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