435294231-3-10-2025-26-AS-DMAO-DEH2S2-20250305163825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294231
Report Date: 03/05/2025
Date Signed: 03/10/2025 09:31:25 AM

Document Has Been Signed on 03/10/2025 09:31 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:	OAK GROVE RESIDENTIAL CARE HOME		FACILITY NUMBER:	435294231
ADMINISTRATOR/ DIRECTOR:	AGUILAR, DEBBIE R.		FACILITY TYPE:	740
ADDRESS:	5459 CENTURY PARK WAY		TELEPHONE:	(408) 229-9479
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95111
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Debbie Aguilar		TIME VISIT/ INSPECTION COMPLETED:	04:45 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 (ADM) Debbie Aguilar. LPA Marrufo toured the facility inside and out. LPA toured the kitchen area. LPA observed locked storage areas for sharp objects and cleaning supplies. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days in the kitchen and food storage areas in the garage. LPA reviewed the first aid kit and observed it to be complete. LPA toured 7 out of 7 resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA tested the smoke detectors in each hallway and in each bedroom, and each smoke detector functioned properly when tested. LPA tested the carbon monoxide detector in the kitchen and it functioned properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had functioning lights and available soap and paper towels. The water temperatures from the bathroom sinks were 110 F and 111 F. LPA toured the outside of the facility and observed the outdoor exit to be clear of obstructions. LPA reviewed the Centrally Stored Medication and Destruction Record (CSMDR) for residents R1-R6. Residents R1 and R2 each had a medication that was not recorded in their CSMDR. LPA reviewed six out of six resident records and four staff records and found them to be complete. The Emergency Disaster Drill Log indicates that the last drill was conducted on 03/01/2025. A deficiency was cited as per California Code of Regulations Title 22. This report was reviewed with ADM Debbie Aguilar and a copy of this report and appeal rights were provided.

Sarah Yip	TELEPHONE: (408) 324-2131
David Marrufo	TELEPHONE: (650) 380-0519
	DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025

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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Document Has Been Signed on 03/10/2025 09:31 AM - 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: OAK GROVE RESIDENTIAL CARE HOME	FACILITY NUMBER: 435294231
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

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

(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	Based on record review, the licensee did not comply with the section cited above in 2 out of 6 Centrally Stored Medication and Destruction Records which poses/posed a potential health risk to persons in care. 2 out of 6 Centrally Stored Medication Records were missing a medication.
	POC Due Date: 03/12/2025
	Plan of Correction
1 2 3 4	Licensee agrees to conduct staff training by POC date on assuring that a record of centrally stored prescription medications for each resident is maintained. Once training is completed, the Licensee agrees to submit training records including names of staff trained, training date(s), and names and qualifications of trainer to CCL.

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.

Sarah Yip	TELEPHONE: (408) 324-2131
David Marrufo	TELEPHONE: (650) 380-0519
	DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025

LIC809 (FAS) - (06/04)

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