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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294212
Report Date: 04/04/2025
Date Signed: 04/04/2025 01:34:41 PM

Document Has Been Signed on 04/04/2025 01:34 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:PERPETUAL HELP CARE HOMEFACILITY NUMBER:
435294212
ADMINISTRATOR/
DIRECTOR:		CARUZ, VIRGILIO O.FACILITY TYPE:
740
ADDRESS:1888 ARROYO DE PLATINATELEPHONE:
(408) 258-1434
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
04/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Virgilio Caruz and Lucena CaruzTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 4/4/2025, Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management visit for deficiencies cited during 1 year required annual inspection and met with administrator/licensee (LIC/ADM) Virgilio Caruz and Lucena Caruz and stated the purpose of the visit.

LPA toured the facility accompanied by LIC/ADM inside and outside, including but not limited to the kitchen, dining room 4 resident bedroom, 2 bathroom and the garage. LPA reviewed the facility record, 4 client records, and 2 staff record and observed the files are current.

ADM stated resident files are currently being updated, for year of 2025. LPA did not observe any obstruction on the walkways, chemicals, sharps and medications are kept in a lock cabinet.

LPA observed 7 days of non-perishable and 2 days of perishable food. The room temperature measures at 70 degrees F and water temperature measured at 96.6 degree F to 99.5 degree F (kitchen and bathroom).

LPA observed a garden fountain that was broken and no longer used that has some standing water. LIC/ADM stated the water was a result of the previous rain and water will be removed. LPA observed broken small engine motor and a broken lawn mower, LIC/ADM stated, those will be sent to recycling and removed from the facility.


page 1 of 2 SEE LIC 809C
Romeo ManzanoTELEPHONE: (650) 388-2297
Maria PartozaTELEPHONE: (669) 308-3994
DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2025
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 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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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: PERPETUAL HELP CARE HOME
FACILITY NUMBER: 435294212
VISIT DATE: 04/04/2025
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A technical advisory was given to the licensee/administrator regarding the importance of keeping the facility well maintained, sanitary and in good repair at all times both inside and outside.

Deficiency is cited during today's visit based on California Code of Regulation (CCR) Title 22. 87303 Maintenance and Operation. An exit interview was conducted with LIC/ADM Virgilio Caruz and Lucena Caruz. A copy of the report and appeals rights were provided.

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end of report
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/04/2025 01:34 PM - It Cannot Be Edited

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: PERPETUAL HELP CARE HOME
FACILITY NUMBER: 435294212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2025
Section Cited
CCR
87303(e)(2)

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87303 Maintenance and Operations (e)Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the
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ADM stated that the facility will monitor and maintain the water temperature for a week. A plan of correction and a memorandum of understanding will be submitted to LPA by the Plan of Correction due date.
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cont- temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This section is not met as evidenced by:
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Based on observation, the water temperature when measure with a digital thermometer was under 105 degree F (96.6 to 99.5 degree F) which, pose/poses an immediate personal rights, health and safety risk to persons in care.
Type B
04/05/2025
Section Cited
CCR87303

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This citation is not valid - technical difficulty.
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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 ManzanoTELEPHONE: (650) 388-2297
Maria PartozaTELEPHONE: (669) 308-3994

DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2025

LIC809 (FAS) - (06/04)
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