435202949-9-22-2025-26-AS-DMAO-DLRVQ7-20250922163753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202949
Report Date: 09/22/2025
Date Signed: 09/22/2025 04:38:03 PM

Document Has Been Signed on 09/22/2025 04:38 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:	GARDENIA HOMES 1 LLC		FACILITY NUMBER:	435202949
ADMINISTRATOR/ DIRECTOR:	YONG, JOSEPHINE		FACILITY TYPE:	740
ADDRESS:	994 SOBRATO DRIVE		TELEPHONE:	(408) 375-7605
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY: 14		CENSUS: 10	DATE:	09/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Josephine Yong		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Administrator Josephine Yong. During visit, LPA toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA reviewed the first aid kit and found it to be complete. LPA Marrufo toured 9 out of 9 resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA toured three out of three resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks ranged from 114 F to 120 F. LPA tested the carbon monoxide and smoke detectors in the hallways and bedrooms. Each detector functioned properly when tested. LPA toured the outside area and found the exits to be clear of obstructions. See LIC809-C page for more information. Page 1 of 2.

NAME OF LICENSING PROGRAM MANAGER: Maria Partoza
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

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: GARDENIA HOMES 1 LLC	FACILITY NUMBER: 435202949
	VISIT DATE: 09/22/2025

NARRATIVE

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LPA reviewed the Centrally Stored Medication and Destruction Records (CSMDR) for 6 residents. 4 out of 6 CSMDR were complete. Resident R1's CSMDR was missing one prescribed medication. R2's CSMDR was missing 1 prescribed medication.

LPA reviewed 6 resident records and found them to be complete.

LPA reviewed 6 staff records. Four out of six staff records were complete. Staff S1-S2 were missing current first aid certifications. S2 was missing a health screening form.

The emergency disaster drill log indicates the last drill was conducted on 07/05/2025.

LPA Marrufo requests that updated copies of the following documents be submitted to the department within seven calendar days:

LIC500 Personnel Report
LIC308 Designation of Administrative Responsibility
Liability Insurance
LIC610E Emergency Disaster Plan

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information.

This report was reviewed with Administrator Josephine Yong and a copy of this report and appeal rights were provided.

Page 2 of 2.

END REPORT

NAME OF LICENSING PROGRAM MANAGER: Maria Partoza
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 09/22/2025 04:38 PM - It Cannot Be Edited

Created By: David Marrufo On 09/22/2025 at 04:12 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: GARDENIA HOMES 1 LLC	FACILITY NUMBER: 435202949
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)(A)-(F)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	During review of 6 resident records, 2 out of 6 resident records each had one prescription medication missing from the Centrally Stored Medication and Destruction Record, which poses a potential safety risk to residents in care.
	POC Due Date: 09/29/2025
	Plan of Correction
1 2 3 4	Licensee agrees to conduct in-service training on ensuring that there is a record of all centrally stored prescription medications with staff by Plan of Correction Due date of 09/29/2025. Once training is completed, the licensee will submit copies of training records, including names of staff trained, training dates, training topics, and names and qualifications of trainers.

Type B

Section Cited

CCR

87412(a)(11)

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	During review of 6 staff records, LPA observed 1 out of 6 staff records was missing an LIC503 Health Screening form, which poses a potential safety risk to residents in care.
	POC Due Date: 09/29/2025
	Plan of Correction
1 2 3 4	Licensee shall submit a copy of staff S2’s LIC503 Health Screening form by Plan of Correction Due Date of 09/29/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Maria Partoza
NAME OF LICENSING PROGRAM MANAGER:

	David Marrufo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 09/22/2025 04:38 PM - It Cannot Be Edited

Created By: David Marrufo On 09/22/2025 at 04:14 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: GARDENIA HOMES 1 LLC	FACILITY NUMBER: 435202949
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement was not met as evidenced by: During review of 6 staff records, LPA Marrufo observed 2 out of 6 staff did not have current first aid certifications, which poses a potential safety risk to residents in care.
	POC Due Date: 09/29/2025
	Plan of Correction
1 2 3 4	Licensee shall submit current first aid certifications for staff S1 and S2 to the department by Plan of Correction Due Date of 09/29/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Maria Partoza
NAME OF LICENSING PROGRAM MANAGER:

	David Marrufo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

LIC809 (FAS) - (06/04)

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