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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294299
Report Date: 05/21/2024
Date Signed: 05/21/2024 11:58:01 AM


Document Has Been Signed on 05/21/2024 11:58 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:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Dave MagnoTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Dave Magno. LPA Rai observed 3 staff and 3 residents at the facility. The facility has 3 elderly developmentally disabled residents who are overseen by San Andreas Regional Center.

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

LPA Rai toured the resident bedrooms. 3 out of 3 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 108.9 degrees F - 111.8 degrees F. The water temperature in the kitchen sink was 106.3 degrees F.

Fire extinguisher was observed and inspected on 6/1/2023. Facility smoke detectors and fire alarm was inspected and passed by a third party agency on 4/3/2024. During visit, LPA Rai and ADM tested carbon monoxide detector in living room and detector was in working condition. The last disaster drill was conducted on 5/10/2024.

LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator (ADM) 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: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
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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