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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202948
Report Date: 07/09/2026
Date Signed: 07/09/2026 11:28:10 AM

Document Has Been Signed on 07/09/2026 11:28 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:VINCENT ADULT RESIDENTIAL FACILITY LLCFACILITY NUMBER:
435202948
ADMINISTRATOR/
DIRECTOR:		JAVIER, JULIUS ERVINFACILITY TYPE:
735
ADDRESS:3353 VINCENT DRTELEPHONE:
(408) 547-7575
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 6CENSUS: 6DATE:
07/09/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Administrator, Julius Ervin JavierTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on an Incident Report received by the Department on 06/23/2026. LPA Rai met with Administrator, Julius Ervin Javier and stated the purpose of today's visit. LPA Rai observed 2 staff and 3 residents at the facility, 3 residents are attending day program.

On 06/23/2026, the Department received an Incident Report for resident (R1) who was taken to urgent care on 06/22/2026 for an assessment on skin redness noted on the lower back area. Per Report, R1 was transferred to the Emergency Room Department and was diagnosed with Stage 1 Pressure Injury. R1's After Visit Summary document dated 6/22/2026 was attached to the Incident Report which stated R1 was diagnosed with Stage 1 Pressure Ulcer.

During today's visit, LPA Rai interviewed 2 staff (S1-S2) and ADM. Three out of three staff stated they noticed R1's skin was red with skin breakage which was a change of condition. They stated R1 has had skin redness in the past but it was resolve on its own. On 06/23/2026, the staff observed the skin redness and skin breakage and took R1 to urgent care and then Emergency Room. They stated R1 was discharged with Stage 1 Pressure injury and they were given a medicated patch to place on R1's skin. ADM stated they created the updated care plan and trained staff on monitoring R1's skin and reporting to R1's primary care physician on any changes to the skin.

Continuation on LIC 809-C, Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2026
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 3
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: VINCENT ADULT RESIDENTIAL FACILITY LLC
FACILITY NUMBER: 435202948
VISIT DATE: 07/09/2026
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ADM stated they had placed an order for a new wheelchair for R1 since R1 was outgrowing the existing wheelchair and staff has provided incontinence care to resident wherein R1 is repositioned every 2 hours as well as the skin area is observed every 2 hours or as needed when R1 has a bowel or urinary episode.

During today's visit, LPA Rai interviewed resident R1. LPA Rai observed R1 assisting staff in repositioning in bed, moving their head and arms in the bed, and assisting staff in dressing, by placing their arms through the arm hole of the shirt.

During today's visit, LPA Rai reviewed R1's Progress Notes, Physician's Report and Appraisal/Needs and Services Plan and R1's Restricted Health Condition Care Plan, including staff training. R1 does not have a history of skin breakdown and Administrator documented facility staff's responsibility to ensure R1 is continued to reposition every 2 hours, monitor signs and symptoms of infection, assess for R1's level of pain and monitor R1's nutrition.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Julius Ervin Javier and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC809 (FAS) - (06/04)
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