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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202923
Report Date: 08/14/2025
Date Signed: 08/14/2025 05:05:43 PM

Document Has Been Signed on 08/14/2025 05:05 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:CALIFORNIA MENTAL HEALTH LLCFACILITY NUMBER:
435202923
ADMINISTRATOR/
DIRECTOR:		ANDERSON, JEANFACILITY TYPE:
772
ADDRESS:14210 LESLEY LANETELEPHONE:
(949) 274-3632
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 6CENSUS: 5DATE:
08/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Josh FaneTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Program Director (PD), Josh Fane.

During visit, LPA toured the facility with the PD to include the living room, kitchen, 4 resident bedrooms, 3 bathrooms, storage spaces, activity room, group room (2nd floor), backyard, and ADU/garage unit. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared and associated to the facility. There are cameras throughout all common areas and exterior areas of the facility.

Facility temperature maintained at 77 degrees F. The facility has a central air-conditioning system that was in use. Fire extinguishers last serviced on 11/19/2024. Facility has a dual smoke and carbon monoxide detector that was tested and observed operable. There were multiple first aid kits throughout the facility for use. Medications and sharp objects observed locked.

Resident bedrooms equipped with proper furniture to include beds, linens, night stands, closet space, and adequate lighting. The hot water temperature was measured in the activity room, which was maintained at 114.2 degrees F. The hot water temperature next to bedroom #3 maintained at 109.2 degrees F. The facility is supplied with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Drinking water available for the clients, when needed. Items inside the refrigerator observed covered and labeled. Refrigerator temperature maintained at 35 degrees F. Freezer temperature maintained at -3 degrees F. Weekly menu posted on the refrigerator. Toxins and chemicals stored separately from the food supply. Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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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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)
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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: CALIFORNIA MENTAL HEALTH LLC
FACILITY NUMBER: 435202923
VISIT DATE: 08/14/2025
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The sliding door leading out to the 2nd floor balcony in the group activity room observed with a key lock for safety purposes.

The backyard is equipped with a shaded seating area which is being used as a smoking area. There is a swimming pool in the backyard which contains a secured and locked fence that is about 5 feet high. In the backyard, LPA and PD entered into the ADU. The ADU is locked at all times and being used for storage items. There is a refrigerator and freezer in this area which the facility's chef stores extra food supplies. The refrigerator temperature maintained at 40 degrees F and freezer temperature maintained at 0 degrees F.

LPA reviewed 3 resident files with the PD. During record review, LPA and PD observed 5 out of 5 resident files did not contain a TB result. PD followed-up with the staff who thought they were able to obtain a TB result within the first 30 days of admission. LPA provided the PD the Title 22 regulation Section 81069. A type A deficiency was cited during today's visit in violation of Section 81069(f)(1) for 5 out of 5 residents who do not have a TB result. 3 residents centrally stored medications and centrally stored medication records reviewed with the PD and medication room staff. There was only 1 medication for 1 resident that was not inputted in the centrally stored medication record. A technical violation was provided during today's visit advising that a record of each centrally stored medication shall be maintained on the centrally stored medication record.

LPA reviewed 5 staff files were complete and up-to-date. 5 out of 5 staff obtains an active first aid certification, fingerprint clearance, health screening, TB result, LIC501 and annual training records. LPA observed staff are provided on-boarding training upon hire and in-service training monthly to include topics (not limited to) crisis interventions, medical emergencies, emergency disasters, medications, infection control, and safe food handling.

Emergency drills are completed quarterly and the last drills was completed on 08/13/2025 and 07/02/2025. Facility has emergency supplies to include non-perishable foods and extra flash lights. LPA advised to ensure the emergency disaster plans are updated and reviewed annually.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Program Director, Josh Fane and a copy of the report and appeal rights were provided. Page 2 of 2.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 05:05 PM - It Cannot Be Edited


Created By: Christine Kabariti On 08/14/2025 at 04:48 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: CALIFORNIA MENTAL HEALTH LLC
FACILITY NUMBER: 435202923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81069(f)(1)
Client Medical Assessments
(f) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/ infectious diseases.

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 wherein 5 out of 5 residents did not have TB results on file prior to admission or within 72 hours of their admission which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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The program director states the facility's LVN has ordered supplies to complete 5 resident's TB testing which will be completed by 08/15/2025. PD states the results should be completed within 48-72 hours. PD states they will submit a written plan to include the steps taken to ensure compliance to LPA Kabariti via email by POC due date of 08/15/2025.
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.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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