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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202926
Report Date: 07/03/2026
Date Signed: 07/03/2026 03:49:58 PM

Document Has Been Signed on 07/03/2026 03:49 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:MAPLEWOOD MANORFACILITY NUMBER:
435202926
ADMINISTRATOR/
DIRECTOR:		VICENTE, ROGELIOFACILITY TYPE:
735
ADDRESS:3281 HEBRON CTTELEPHONE:
(650) 776-9173
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 4CENSUS: 3DATE:
07/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Staff Jocyline PatioTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff Jocyline Patio, referred to as S1. During the visit, LPA observed 2 residents and 1 staff. LPA explained the purpose of the visit. Maplewood Manor is a level 4 home.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. There was no obstruction to block the walkways. The staff area of the facility was also inspected. The front yard and backyard were inspected.

While touring the facility kitchen, LPA asked S1 to show LPA where the knives are being stored. S1 opened the cabinet, next to the oven, on the bottom left side. LPA observed the cabinet which housed the knives did not have a lock. LPA informed S1 that knives must be inaccessible to residents in care. S1 relocated the knives to a secured location during the visit. While touring the backyard, LPA noted a green/white spay bottle of insect repellant, in the side of the home, adjacent to the family room. LPA informed S1 that items that could pose a danger to residents must be inaccessible. S1 secured the insect repellant during the visit. LPA also toured the side of the home adjacent to room 2. LPA observed the following was accessible to residents in care: outdoor cleaner, paint. S1 secured the items during the visit.

LPA toured the facility hallway bathroom. LPA observed toilet cleaning detergent on the left side of the toilet. LPA observed in the mirror/cabinet, contained 2 unsecured medications. S1 stated he/she isn't sure who's medications those belong to.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2026
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 6
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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Document Has Been Signed on 07/03/2026 03:49 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/03/2026 at 03:09 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: MAPLEWOOD MANOR
FACILITY NUMBER: 435202926

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Throughout today's visit, LPA observed multiple instances where items that could pose a danger to residents, were accessible to residents in care. Some of these accessible items include toilet cleaner and medication tablets in the bathroom, knives in the kitchen, insect repellant, pain, outdoor cleaner in the backyard. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2026
Plan of Correction
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ADM stated he will provide a re-training for all his staff regarding Disinfectants, medications, knives, cleaning solutions, poisons, firearms and other items that could pose a danger to residents if accessible. ADM stated he will send LPA documentation showing this training has taken place. ADM stated he will also send a letter of understanding regarding the regulation and the importance of ensuring dangerous items are inaccessible to residents in care. POC due July 4, 2026.
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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/03/2026 03:49 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/03/2026 at 03:09 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: MAPLEWOOD MANOR
FACILITY NUMBER: 435202926

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records reviewed the licensee did not comply with the section cited above.LPA asked to review S1's training for the year 2025 and 2026. S1 stated he/she has not completed any training for 2025 and 2026. LPA asked to review S3's training. LPA was not provided any documentation for review. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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ADM stated he will provide Staff S1 and S3 with training. ADM stated he will send LPA documentation showing the training for S1 and S3 has taken place. ADM stated he will also send a plan of action on how he will ensure his staff has been provided annual training and how he will ensure it will be completed and documented. ADM stated he will send the plan of action to LPA by POC due date, July 10, 2026.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records reviewed, the licensee did not comply with the section cited above.LPA asked S1 for a copy of his/her first aid training. S1 stated he/she has not had a chance to renew his/her first aid training. LPA asked to review S3's first aid training. LPA was not provided any documentation for review. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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ADM stated Staff S1 and S3 will complete their first aid training and send documentation to LPA confirming that have completed their first aid training. ADM stated the plan of correction will be sent to LPA by POC due date, July 10, 2026.
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:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2026 03:49 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/03/2026 at 03:19 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: MAPLEWOOD MANOR
FACILITY NUMBER: 435202926

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above. LPA noted the facility garage does not reflect the approved facility sketch. LPA observed the facility garage has had 2 bedrooms have been created. S1 stated the licensee did not notify the Department of Social Services Community Care Licensing of this change. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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ADM stated he will send the Department a letter requesting an updated fire clearance, to reflect the changes that have been made in the garage. ADM stated he will also send a copy of the building permits for the garage conversion. ADM stated he will send the written plan of correction to LPA by POC due date, July 10, 2026.
Type B
Section Cited
CCR
80075(k)(7)
80075 Health Related Services (k)(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above. LPA noted R2 had 3 medications that were not listed on the Centrally stored medication record. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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ADM stated he will send a written plan of action on how he will ensure the maintenance, for each client, of a record of centrally stored prescription medications. ADM stated he will send the written plan of action to LPA by POC due date, July 10, 2026.
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:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
Page: 5 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: MAPLEWOOD MANOR
FACILITY NUMBER: 435202926
VISIT DATE: 07/03/2026
NARRATIVE
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LPA toured the facility garage. LPA noted the facility garage does not reflect the approved facility sketch. The facility sketch shows the facility garage as a garage. On July 3, 2026, LPA observed the facility garage has had 2 bedrooms have been created. LPA asked S1 if the Licensee obtained a permit for the changes in the garage. S1 stated the Licensee did obtain a permit for the changes in the garage. S1 stated the licensee did not notify the Department of Social Services Community Care Licensing of this change.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 72 degrees F, and hot water temperature was measured at 114 degrees F in resident bathrooms.

S1 stated the Fire extinguisher is scheduled to be serviced on July 7, 2026. LPA requested a copy of the updated fire extinguisher and tag once it has been updated. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on May 1, 2026. LPA reviewed facility disaster plan, which was last reviewed/updated on February 1, 2026

LPA reviewed facility records for 3 staff and 3 residents. LPA asked S1 for a copy of his/her first aid training. S1 stated he/she has not had a chance to renew his/her first aid training. LPA asked to review S1's training for the year 2025 and 2026. S1 stated he/she has not completed any training for 2025 and 2026. LPA asked to review S3's first aid training and general training. LPA was not provided any documentation for review.

LPA reviewed 3 resident medications and centrally stored medication records. LPA noted R2 had 3 medications that were not listed on the Centrally stored medication record.

Deficiencies cited during today's visit, See LIC809-D. This report was reviewed with Staff Jocyline Patio and a copy of the signed report was provided. Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026
LIC809 (FAS) - (06/04)
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