<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202917
Report Date: 02/13/2025
Date Signed: 02/13/2025 11:51:58 AM

Document Has Been Signed on 02/13/2025 11:51 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/
DIRECTOR:		OVISO, PORTIAFACILITY TYPE:
735
ADDRESS:3175 SYLVAN DRTELEPHONE:
(408) 891-7016
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Portia OvisoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator (ADM) Portia Oviso and stated the purpose of today's visit. LPA Rai observed 3 staff 3 residents at the facility as 3 residents are out of the facility. The facility is vendorized by San Andreas Regional Center and is a level 4g facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 2 mattresses in the garage. ADM stated 1 mattress belonged to the hospital bed which will be picked up by a third party vendor and 1 mattress is used by a resident when the current mattress is soiled. LPA Rai did not observe any personal items such as clothing or personal cleaning items. LPA Rai stated as per CCR 85087(a)(3)(A) Buildings and Grounds: No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings. Administrator agreed and understood.

LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the facility to include 4 resident rooms, living room, family room, dining room, kitchen and garage. 4 Out of 4 resident bedrooms had available bedding, drawers, and functioning lights.  The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom and kitchen sink ranged from 118.6 - 119.5 degrees F.

Continuation LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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 6
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: 02/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2 of 2.

Fire extinguisher was observed and inspected on 10/13/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 1/8/2025 and 2/11/2025.  LPA Rai observed a complete first aid kit at the facility.

LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed S2's facility file and observed LIC 503 Health Screening Report was not available for review. ADM and S2 stated the Health Screening Report was not been completed and does not have a Health Screen Report completed one year prior to employment.

LPA Rai reviewed resident medications and central stored medication records.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC 809-D.

Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator (ADM) Portia Oviso and a copy of the report was provided. Appeal Rights were provided. LIC 858 and LIC 859 were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/13/2025 11:51 AM - It Cannot Be Edited


Created By: Simranjit Rai On 02/13/2025 at 11:21 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: ELLIE REESE CARE HOME LLC
FACILITY NUMBER: 435202917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 2 staff files did not contain the LIC 503 Health Screening Report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
1
2
3
4
Administrator stated to submit a written plan of action understanding regulation and will ensure a plan is created for S2 to complete the LIC 503 Health Screening Report by POC due date. Administrator agreed and understood.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6