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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202930
Report Date: 07/24/2025
Date Signed: 07/24/2025 05:13:52 PM

Document Has Been Signed on 07/24/2025 05:13 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:SHIRAN 2 CARE MANAGEMENT INC.FACILITY NUMBER:
435202930
ADMINISTRATOR/
DIRECTOR:		URENA, AIDAFACILITY TYPE:
735
ADDRESS:821 ESCHENBURG DRTELEPHONE:
(408) 649-8537
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 5DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Deysi SerafinTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. Administrator, Aida Urena was contacted who stated to be currently on vacation during the day of visit and unable to meet LPA. LPA met with designated Administrator/House Manager, Deysi Serafin.

During visit, LPA toured the facility with staff to include 3 resident bedrooms, 2 bathrooms, kitchen, living room, garage and backyard. The shed in the backyard was observed and no issues were noted. The backyard is equipped with a shaded seating area. 2 staff members present are fingerprint cleared and associated to the facility.

Facility temperature maintained at 71 degrees F. Fire extinguisher observed in the kitchen area. Carbon monoxide detector in the kitchen area observed operable. Resident bedrooms are equipped with proper furniture and adequate lighting. Bathroom hot water temperature maintained at 117 degrees F. Kitchen is equipped with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 38 degrees F. Freezer temperature maintained at 0 degrees F. Cleaning solutions stored in a locked separate cabinet from the food supply. Sharp objects and medications observed locked.

LPA reviewed 5 resident files. Based on record review, 1 resident (R5) who was admitted on 07/02/2025, file did not include an admission agreement, needs and services plan, functional capabilities assessment, consent forms, safeguard of personal properties and valuables, and personal rights. Page 1 of 3.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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)
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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: SHIRAN 2 CARE MANAGEMENT INC.
FACILITY NUMBER: 435202930
VISIT DATE: 07/24/2025
NARRATIVE
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1 resident (R4)'s file did not have an admissions agreement, physician's report, TB result, safeguard of personal properties and valuable, consent form and personal rights.

5 out of 5 residents did not have a functional capabilities assessment on file. 5 out of 5 resident files did not contain a signed consent for medical treatment form.

5 resident's centrally stored medications and centrally stored medication records were reviewed with staff. LPA advised licensee to ensure the centrally stored medication records are completed accurately to include the start dates as R3's centrally stored medication record did not include start dates. Facility has a PRN sheet and medication administration record.

4 out of 5 residents has P&I money, which was reviewed and counted with the staff. It was observed that the actual amount of money the resident had was over the amount written in the cash resource log for 2 residents. Facility was verbally advised to ensure the actual amount on hand matches with the amount written in the log.

LPA reviewed 3 staff files. 3 out of 3 staff files contained a fingerprint clearance, 1st aid certification, health screening, TB result and job application.

Facility does not have an updated infection control plan. Licensee was advised to ensure the infection control plan is reviewed and updated annually. Infection control supplies observed to include gloves and sanitation/disinfectant solutions.

Facility has an emergency disaster plan. LPA advised to review and update the emergency disaster plan annually. LPA observed the facility has complete first aid kits, flashlights, and emergency backpack kits. Since the facility accepted their first resident in January 2025, the facility has not completed any emergency drills.

Page 2 of 3.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/24/2025 05:13 PM - It Cannot Be Edited


Created By: Christine Kabariti On 07/24/2025 at 04:13 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: SHIRAN 2 CARE MANAGEMENT INC.
FACILITY NUMBER: 435202930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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 the licensee has not completed emergency drills since the acceptance of the first resident in January 2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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Licensee will submit written plan as part of the plan of correction (POC) to ensure emergency drills are conducted quarterly moving forward. Licensee will submit the POC to LPA Kabariti via email by POC due date of 07/31/2025.
Type B
Section Cited
CCR
80070(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

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 in 5 counts wherein each residents file were not observed complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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Licensee will submit a statement of understanding of the section cited above to ensure all resident records are complete and current to include all items listed in Section 80070(b)(1 - 14). Licensee will submit the statement of understanding to LPA Kabariti via email by POC due date of 07/31/2025.
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: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: SHIRAN 2 CARE MANAGEMENT INC.
FACILITY NUMBER: 435202930
VISIT DATE: 07/24/2025
NARRATIVE
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Documents were requested by 07/31/2025 to update the facility's file:
- Emergency Disaster Plan
- Infection Control Plan
- Personnel Report (LIC500)
- Administrator Certificate
- Designation of Facility Responsibility (LIC308)

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-Ds.

This report was reviewed with designated Administrator/House Manager, Deysi Serafin and a copy of the report and appeal rights were provided.

Page 3 of 3.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
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