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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202921
Report Date: 03/08/2024
Date Signed: 03/08/2024 02:21:59 PM

Document Has Been Signed on 03/08/2024 02:21 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:GLENGROVE RESIDENTIAL CARE HOME, LLCFACILITY NUMBER:
435202921
ADMINISTRATOR:DUMANTAY, ERWINFACILITY TYPE:
735
ADDRESS:3889 GLENGROVE WAYTELEPHONE:
(408) 728-5505
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
03/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrator Erwin DumantayTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Manuel Monter arrived announced to conduct the facility's pre-licensing visit. LPA met with Administrator (ADM) Erwin Dumantay. LPA observed 2 residents and two staff during visit. The other 3 residents were attending day program during LPA's visit.

During visit, LPA toured the facility inside and out. The tour of the facility included the living room, 5 resident bedrooms, 3 bathrooms, garage, kitchen/dining room, and backyard.

While touring the backyard, LPA observed bedroom #2 does not have a sliding door screen. LPA also observed the screen for bedroom #6 is damaged and has 3 pieces of tape covering up holes. While touring the backyard, near bedroom #3's door, LPA observed an unsecured storage shed. LPA observed the shed did not have a lock and inside the shed was cans of paint and tools. ADM stated he could not find the lock but would address the issue.

While touring resident bedroom #4, LPA observed a large blue, stars and moon sticker on the bottom of the glass sliding closet door, directly across from bathroom #2. LPA observed at the edges of the sticker, the glass was split. LPA asked ADM to remove the sticker. LPA observed there glass was cracked. (Photographs were taken.) While touring bathroom #1 LPA observed the grab bar directly above the toilet did was not secure and screws were not fully secured. (Photographs were taken.) While touring resident bedroom #1, LPA observed a section next to the bed that is not painted.

Facility was observed to be clean. Fire exit routes were clear and free of obstructions. Carbon monoxide detectors was tested and observed to be functioning properly. Fire extinguisher was purchased in October 16, 2023. Bathroom hot water temperature was measured to range from 107-109 degrees F. Facility temperature observed to be 72 degrees F. First Aid Kit observed to be complete. No open bodies of water noted at facility. Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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: GLENGROVE RESIDENTIAL CARE HOME, LLC
FACILITY NUMBER: 435202921
VISIT DATE: 03/08/2024
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Medication cabinet observed to be locked. Facility kitchen equipment is functioning properly, LPAs observed locked drawer for sharps. LPAs reviewed emergency disaster plan and confirmed its completeness. LPAs observed storage closed for containment of cleaning chemicals. Facility bulletin board contain all necessary documents.

LPA observed 7 days of perishable and non perishable food supplies. LPA observed a locked cabinet in the kitchen for sharps and chemical products. LPA observed the facility's business license and facility sketch. AP will post the posters in the facility. The facility has designated locked medication cabinets.

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) The broken glass closet sliding door in bedroom #4
2) Missing paint in bedroom #1
3) The unlocked storage shed
4) The unsecured grab bar in bathroom #1
5) The missing non-skid mats in bathrooms #2 and #3.
6) The missing sliding screen door for bedroom #4
7) The damaged screen for bedroom #6

ADM stated the residents will be remain in the home during the change of ownership. ADM stated he also informed the families and San Andreas Regional Center.

ADM 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 Administrator Erwin Dumantay and a copy of the report was provided.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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