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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202927
Report Date: 06/19/2025
Date Signed: 06/19/2025 11:51:38 AM

Document Has Been Signed on 06/19/2025 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:CASA DE REYESFACILITY NUMBER:
435202927
ADMINISTRATOR/
DIRECTOR:		MIRANDA, LEOFELMAFACILITY TYPE:
735
ADDRESS:7566 ALEXANDER STREETTELEPHONE:
(408) 848-6672
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
06/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Leofelma MirandaTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
NARRATIVE
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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 Administrator (ADM), Leofelma Miranda.

During visit, LPA toured the facility with the ADM to include 3 resident bedrooms, 2 bathrooms, living room, kitchen, 1 staff bedroom, office, and exterior. All emergency exits were free and clear of obstruction. 3 staff present are fingerprint cleared and associated to the facility. All residents were attending day program and were not present inside the facility.

Facility temperature maintained at 73 degrees F. Resident bedrooms equipped with beds, linens, night stand, adequate lighting, and closet space. Bathroom shower observed with a non-slip mat and grab bar. Bathroom hot water temperature maintained at 116.6 degrees F. Facility is equipped with at least 7 days worth of non perishable and 2 days worth of perishable foods. Refrigerator temperature maintained at 30 degrees F. Freezer temperature maintained at 0 degrees F. Sharp objects, chemicals, disinfectants, and medications observed in locked cabinets.

Facility has a complete first aid kit. Facility has an updated emergency disaster plan and infection control plan. Fire drills are completed quarterly and the last drill was completed on 04/01/2025. Fire extinguisher last serviced 05/02/2025. Carbon monoxide detector observed in the kitchen. See LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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: CASA DE REYES
FACILITY NUMBER: 435202927
VISIT DATE: 06/19/2025
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3 staff files were reviewed. 3 staff are fingerprint cleared, has an active 1st aid certification, health screening, TB result, and staff training.

3 resident files were reviewed were observed complete and up-to-date. 3 residents centrally stored medications and centrally stored medication records reviewed and observed maintained with all medications accounted for. 3 residents P&I money was counted with the ADM and all money was accounted for.

During record review of resident files, it was observed that 1 resident who was admitted in March 2025 has a restricted health condition for the use of an inhalation-assistive device. Based on record review, the facility does not have an approved restricted health condition care plan and the staff were not trained prior to the resident's admission for the use of the resident's inhalation-assistive device.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Administrator, Leofelma Miranda and Licensee Michelle Villareal and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/19/2025 11:51 AM - It Cannot Be Edited


Created By: Christine Kabariti On 06/19/2025 at 11:06 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: CASA DE REYES
FACILITY NUMBER: 435202927

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092.1(a)
(a) A client with a restricted health condition specified in Section 80092 may be admitted or retained in an adult CCF if all requirements in Sections 80092.1(b) through (o) are met.

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 1 resident who has an inhalation-assistive device does not have an approved restricted health condition care plan and staff training prior to admission which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2025
Plan of Correction
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Licensee will submit the restricted health condition care plan and staff training to LPA Kabariti via email by POC due date of 06/26/2025.
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: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
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