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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294299
Report Date: 05/31/2023
Date Signed: 06/01/2023 09:18:18 AM


Document Has Been Signed on 06/01/2023 09:18 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:MERIDIAN MANOR 2 LLC (RCFE)FACILITY NUMBER:
435294299
ADMINISTRATOR:MAGNO, DAVEFACILITY TYPE:
740
ADDRESS:5486 YALE DRIVETELEPHONE:
(408) 532-7304
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:3CENSUS: 3DATE:
05/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Dave MagnoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator Dave Magno. LPA Rai observed 4 staff and 3 residents at the facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed a deflated air mattress outside next to the exit door outside of R3's room. The exit door was not obstructed. Administrator (ADM) Dave Magno stated the family was notified today 5/31/2023 to remove the mattress since the resident refused to throw the mattress away. ADM stated the mattress will be picked up by the family within 2 weeks, by 06/14/2023.

LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food supply and at least 7 days of nonperishable food supply. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

The facility bathroom had available soap, paper towels, and trash cans with lids. The shower had grab bars, non-skid mats and and a shower chair. The water temperature in the bathroom sinks ranged from 114.6F-116.4F. The water temperature in the kitchen sink was 118.4F. Fire extinguisher was observed and inspected on April 2022. Facility scheduled fire extinguisher inspection for tomorrow 6/1/2023. Facility smoke detectors was tested by Integrated Fire Systems, Inc on 4/19/2023. Three out of three resident bedrooms had available bedding, drawers, and functioning lights.

LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai reviewed resident medications and central stored medication records. LPA Rai conducted interviews with 3 staff (S1-S3).

Technical Violation note was provided. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Dave Magno and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
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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