<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202639
Report Date: 11/20/2024
Date Signed: 11/20/2024 11:50:46 AM

Document Has Been Signed on 11/20/2024 11:50 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:EDMUND MANORFACILITY NUMBER:
445202639
ADMINISTRATOR/
DIRECTOR:		CARLONE, MICHAELFACILITY TYPE:
735
ADDRESS:2077 EDMUND LANETELEPHONE:
(831) 475-0888
CITY:CAPITOLASTATE: CAZIP CODE:
95010
CAPACITY: 4CENSUS: 4DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Administrator Katherine BlessingTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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) Marcella Tarin conducted an unannounced annual inspection. LPA met with Administrator (ADM) Katherine Blessing. LPA toured the facility inside and out with the Administrator to include the living room, dining room, kitchen, client bedrooms, bathrooms, and exterior. All emergency exits were observed to be clear of obstruction. LPA observed 0 clients during visit. ADM stated all 4 clients were attending program.

LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Hot water temperature range was measured at 114.4 F to 115.7F.
Refrigerator temperature maintained at 40 degrees F and freezer maintained at 0 degrees F. LPA observed toxins, sharps and chemicals locked and inaccessible to residents.

LPA toured 4 client bedrooms. 3 out of 3 client bedrooms had beds, a dresser, functioning lights, storage space for personal belongings, and clean bedding.

The front yard and backyard of the facility was also inspected, along with the locked storage sheds. There was no obstruction to block the outdoor exits.

The facility was equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 12/21//2023. LPA observed the facility first aid kit, and it was observed to be complete. The facility fire/earthquake drill log was reviewed, and drills are being conducted monthly. The last fire drill was conducted on 11/2/2024.


See LIC809C
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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 2
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: EDMUND MANOR
FACILITY NUMBER: 445202639
VISIT DATE: 11/20/2024
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
26
27
28
29
30
31
32
LPA reviewed 2 out of 2 staff records. LPA observed 2 out of 2 records as complete to include fingerprint clearance, health screening, TB result, personnel record, and staff training.

LPA reviewed 2 out of 2 client records. LPA observed 2 out of 2 client records as complete to include appraisal/needs service plans, medical assessments, identification and emergency contact information, personal rights, TB results and consent forms.

LPA reviewed 2 clients Centrally Stored Medication and Destruction Records (CSMDR). LPA observed 2 out of 2 CSMDRs are complete with all medications accounted and documented. LPA observed the medication storage area was locked and inaccessible to clients.

LPAs reviewed 2 out of 2 clients P&I to be accurate and all money documented.


No deficiencies cited during today's visit. An exit interview was conducted with Administrator Katherine Blessing A copy of this report was provided to Administrator.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2