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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202918
Report Date: 07/13/2026
Date Signed: 07/13/2026 04:53:30 PM

Document Has Been Signed on 07/13/2026 04:53 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:UMBRELLA RESIDENTIAL CAREFACILITY NUMBER:
435202918
ADMINISTRATOR/
DIRECTOR:		VALLARTA, ANABELEN D.FACILITY TYPE:
740
ADDRESS:4623 MANGRUM DRIVETELEPHONE:
(510) 709-7078
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 6CENSUS: 5DATE:
07/13/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:40 PM
MET WITH:Administrator, Anabelen VallartaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced complaint investigation visit. LPA Rai met with Administrator, Anabelen Vallarta and stated the purpose of today's visit. LPA Rai observed 5 residents and 2 staff at the facility.

During visit, LPA and LPM observed resident (R2) tied to the wheelchair. There was a thick grey and black gait belt that tied the resident's torso with the back of wheelchair. The buckle of the gait belt was at the back of the wheelchair which was inaccessible to resident. Staff (S1) stated they use the gait belt to make sure R1 does not slide down on the wheelchair. ADM stated R2's family requested facility staff to use the gait belt to tie against the wheelchair. ADM and staff stated that R2 slides from the wheelchair.

During visit, LPA and LPM observed the office area and the garage area was being observed as a living space. Staff S1 stated they sleep in the office area and two other staff sleep in the garage area. ADM confirmed 2 staff use the garage as habitual space. The facility does not have a building permit for the garage to be used as a habitual space.

LPM observed 5 residents' beds except 1 hospice had half-bed rails attached to the bed. ADM stated resident's have physician's order for half-bed rail for mobility.

LPM and LPA reviewed 2 resident files and ADM needs to be aware of resident's responsible party and/or resident has been signed and dated.

Continuation on LIC 809-C, Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2026
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
Document Has Been Signed on 07/13/2026 04:53 PM - It Cannot Be Edited


Created By: Simranjit Rai On 07/13/2026 at 04:16 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: UMBRELLA RESIDENTIAL CARE
FACILITY NUMBER: 435202918

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2026
Section Cited
CCR
87307(a)(2)(B)

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87307 Personal Accommodations and Services (a) (2) (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building.
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Licensee/Administrator stated to submit a written plan of action to ensure garage and hallway are not being used as habitual space by POC due date.
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This requirement is not met as evidence as:
Based on observation, S1 and ADM admitted to staff living in the garage and hallway leading towards exit which poses/posed an immediate health, safety and/or Personal Rights to residents in care.
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Type A
07/14/2026
Section Cited
CCR87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a)(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Licensee/Administrator stated to submit a written plan of action to ensure resident is not being held against the wheelchair with a gait belt by POC due date.
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This requirement is not met as evidence as:
Based on observation, R2 was tied to the wheelchair with a gait belt wherein R2 was not able to go to restroom on their own without staff removing the gait belt around the torso which poses/posed an immediate health, safety, and/or Personal Rights to
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(con't) residents in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Simranjit Rai
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2026 04:53 PM - It Cannot Be Edited


Created By: Simranjit Rai On 07/13/2026 at 04:25 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: UMBRELLA RESIDENTIAL CARE
FACILITY NUMBER: 435202918

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2026
Section Cited
CCR
87309(a)

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87309 (a)...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action to ensure cleaning solutions such as laundry detergents is in locked storage and not left attended by POC due date.
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Based on observation, LPA and LPM observed cleaning solutions such as laundry detergents in the garage with an unlocked door which was accessible to residents in care which poses/posed an immediate health, safety and/or Personal Rights to residents 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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Simranjit Rai
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2026


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: UMBRELLA RESIDENTIAL CARE
FACILITY NUMBER: 435202918
VISIT DATE: 07/13/2026
NARRATIVE
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Page 2 of 2.

LPM and LPA addressed ADM needed to ensure staff had access to resident's file at all times.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator, Anabelen Vallarta and a copy of the report was provided. Appeal Rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2026
LIC809 (FAS) - (06/04)
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