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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202930
Report Date: 08/18/2025
Date Signed: 08/18/2025 05:12:30 PM

Document Has Been Signed on 08/18/2025 05:12 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:
08/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Aida Urena, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. LPA met with Administrator (ADM) Aida Urena.

The purpose of the visit is to follow-up on an incident report received on 08/13/2025 regarding missed medications for resident (R1) that occurred on 08/11/2025. It was reported that on 08/11/2025 at 5:30pm, 2 of R1’s routine medications were not administered as prescribed.

Based on interview with the Administrator (ADM), it was stated that at the time, staff (S1) was assigned as a charge staff to assist with medications. The medication error was discovered during the NOC shift medication count wherein the ADM was informed about an over count of medications. ADM states to have counted the medications the next day (08/12/2025) to confirm the medication error. ADM states that upon following up with S1, S1 stated that the shift was "chaotic" and thought to have assisted R1 with his/her 5:30pm medication. ADM confirmed the medication was not given based on the medication counts conducted daily during NOC shift.

ADM stated R1 was the only resident who missed their 5:30PM and no other residents was affected. It was stated that after it was discovered that R1’s medications were not administered, the Administrator informed R1’s physician, responsible party, and submitted the incident report to the regional center and licensing. It was stated that R1 did not show any signs of discomfort or withdrawals from missing the 2 medications.
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NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2025
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: SHIRAN 2 CARE MANAGEMENT INC.
FACILITY NUMBER: 435202930
VISIT DATE: 08/18/2025
NARRATIVE
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A type A deficiency was cited today on Section 80075(b) wherein R1 was not assisted with 2 of his/her routine medication on 08/11/2025 resulting in R1 missing 2 of his/her routine medications. See LIC809-D.

A type A deficiency was also cited today on Section 80065(a) wherein the staff (S1) was not competent to provide R1 with his/her routine medication as S1 forgotten to assist R1 with his/her 5:30PM medication after a "chaotic" evening. See LIC809-D.

In the incident report and verbally confirmed by the ADM, it’s stated that disciplinary actions have been taken verbally and in writing against S1. ADM states that S1 will complete a refresher medication administration training and will not assist with medications until training is completed. During visit, ADM states that after the incident, S1 had taken personal time off and has not returned to work to complete the training.

During visit, 2 staff members were observed with 5 residents. LPA observed that a staff member (S2) was working in the facility without association to the facility roster. LPA Kabariti reviewed the Guardian website and confirmed that S2 is fingerprint cleared. S2 is associated to the Licensee’s other facility but the Licensee did not transfer S2’s fingerprints to this facility.

Based on review of the facility's Guardian roster, S1 obtained a fingerprint clearance but was also not associated to the facility roster. S1 is associated to the Licensee's other facility.

During visit, the Administrator immediately filled out the transfer request LIC9182 forms and emailed S1 and S2's transfer request form to the Department. LPA observed the Licensee has access to Guardian, however, this facility was not added to their Guardian account. Licensee and Administrator will be working on adding this facility to their Guardian account to access this facility's roster. A technical violation was issued for Section 80019(e)(3) reminding the Administrator and Licensee to ensure all staff's criminal record clearance is transferred to the appropriate facility prior to working in the facility.

Deficiencies were cited today per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator, Aida Urena 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: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2025 05:12 PM - It Cannot Be Edited


Created By: Christine Kabariti On 08/18/2025 at 02:58 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: 08/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2025
Section Cited
CCR
80065(a)

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(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by:
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Administrator removed S1 from assisting with medications and states that S1 will not assist with medications until re-training is completed. Administrator states a plan to train staff on ensuring there is a witness when staff are dispensing and administering medications to the resident.
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Based on interview, record review and observation the licensee did not comply with the section cited above wherein on 08/11/25 the staff (S1) was not competent to assist R1 with his/her 5:30PM routine medications as S1 stated to have forgotten to administer the medication which poses an immediate health, safety, and personal rights risk to persons in care.
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Administrator states to submit the in-service training document regarding the importance of ensuring there is a witness when dispensing medications to LPA Kabariti via email by POC due date on 08/19/2025.
Type A
08/19/2025
Section Cited
CCR80075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
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Administrator states a plan to conduct an in-service training with staff on medication administration. Administrator states to submit the in-service training document to LPA Kabariti via email by POC due date of 08/19/2025.
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Based on interview and record review, the licensee did not comply with the section cited above wherein the staff did not assist resident (R1) with 2 of his/her routine medication on 08/11/2025 resulting in 2 missed medications which poses an immediate health, safety and personal rights risk to persons in care.
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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: 08/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2025


LIC809 (FAS) - (06/04)
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