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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202985
Report Date: 07/21/2026
Date Signed: 07/21/2026 11:47:23 AM

Document Has Been Signed on 07/21/2026 11:47 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:MINA'S ELDERLY CARE HOME @ VASONAFACILITY NUMBER:
435202985
ADMINISTRATOR/
DIRECTOR:		ABBASVAND, MINAFACILITY TYPE:
740
ADDRESS:642 VASONA AVENUETELEPHONE:
(408) 348-8361
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY: 6CENSUS: 5DATE:
07/21/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Mina Abbasvand. TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Manuel Monter, Simi Rai, Coryse Ngangmenyi and Licensing Program Manager (LPM) Romeo Manzano, conducted an unannounced case management visit - other and met with Administrator Mina Abbasvand.

During today's visit, LPA's and LPM noted that Resident R1, in bedroom #5 had a bed with full bed rails.
ADM confirmed that resident R1 is not under hospice and required full bed rail due to safety and history of falls.

LPAs' and LPM observed during the tour that the facility designated exits door knobs in bedroom #6 (staff bedroom based on the physical floor plan) has a main door leading to the main exit door. Both door knobs did not have a single action mechanism to access door in case in a fire emergency. All 6 residents (R1 to R6) have neurocognitive disorders who may not be able to operate or open the door with two separate locking mechanism. LPAs and LPM suggested that bedroom#6 main door must be open or unlocked at all times and the main exit to have a single action mechanism. Noted that Bedroom #6 is a staff bedroom, staff must locked their personal items that could posed safety hazard such as prescription or non-prescription medications and toxins for the safety of residents in care.

LPAs' and LPM also noted that the main entrance door has two locking mechanism. LPAs' and LPM suggested that the main entrance door should have a single action mechanism. ADM stated that she will ensure all designated exit doors will replaced to a single action door locking mechanism. ADM agreed and understood.

Page 1. See page 2 of 2 Continuation
Romeo Manzano
Manuel Monter
DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2026
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 4
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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Document Has Been Signed on 07/21/2026 11:47 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Manuel Monter On 07/21/2026 at 10:10 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: MINA'S ELDERLY CARE HOME @ VASONA
FACILITY NUMBER: 435202985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
07/22/2026
Section Cited
CCR
87608(a)(5)(B)

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87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except ... receiving hospice care ...for full bed rails.

This requirement was not met as evidenced by:
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Licensee/Administrator will updated R1's physican's report, noting that he/she requires the half side rail for mobility. ADM stated she will add a bed alarm on R1' bed. ADM stated she will also updated Resident R1's care plan. ADM stated she will send plan of correction to LPA by POC due date 7/22/2026.
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Based on interview and observation, LPA's and LPM noted that reisdent R1 has a hospital bed with full railing, in bedroom #5. ADM confirmed that R1 was not under hospice care but he/she needs it due to fall risk and also, has neurocognitve disorder.
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(Continue) This poses/posed a potential health safety, personal rights risk to residents 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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: MINA'S ELDERLY CARE HOME @ VASONA
FACILITY NUMBER: 435202985
VISIT DATE: 07/21/2026
NARRATIVE
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LPAs and LPM also reviewed R1 facility file. LPAs and LPM noted that R1 history of fall is not noted on the Appraisal Needs and Services based on ADM's statement that the facility has awake night staff, and that R1 is being checked throughout the day and night while in bed utilizing full bed rails. ADM stated that R1's full bed rail has a Medical Note for safety use only.

LPAs and LPM discussed the difference between 1/2 rail is for mobility only and full bed rails is prohibited unless the resident is under hospice care. Also the difference between Palliative Care and Hospice. ADM stated that R1's family is in discussion with R1's PCPs regarding Palliative care for R1.

ADM stated that R1's Appraisal Needs and Care Plan will be updated including reviewing all of their residents'.

Deficiencies are cited during today's visit, see LIC809-D. Exit interview was conducted with Administrator Mina Abbasvand and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC809 (FAS) - (06/04)
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