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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202713
Report Date: 12/31/2024
Date Signed: 10/22/2025 11:40:22 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/22/2025 11:40 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:RACHELLE'S HOME IFACILITY NUMBER:
445202713
ADMINISTRATOR/
DIRECTOR:		RECINTO, RACHELLEFACILITY TYPE:
740
ADDRESS:99 AIRPORT BLVDTELEPHONE:
(831) 319-4190
CITY:FREEDOMSTATE: CAZIP CODE:
95019
CAPACITY: 12CENSUS: 8DATE:
12/31/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Yuly Romero, Office ManagerTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management - Annual Continuation Visit and met with Office Manager, Yuly Romero. This annual inspection is a continuation of the annual visit that was conducted on 12/27/2024.

LPA reviewed 9 client records. 9 out 9 client records contained emergency contact information, physician's reports and needs/service plans.

LPA reviewed 5 staff records. 5 out of 5 staff records included background fingerprint clearance, health screenings with TB results, and staff training. S3, S4 and S5 did not include first aid certification. S5 record was unavailable for review. Staff stated S3, S4 and S5 obtained first aid certification and will submit copies to the department. Staff stated S5 record was not at the facility. LPA advised staff to ensure all staff files were available for inspection by the Department.

During tour LPA measured water temperature at 116.3 degrees F for the facility.

LPA observed damaged flooring in the hallway outside bedroom #1, and damaged blinds in bedroom #5, and dark spots on the ceiling of bathroom #1, and water damaged areas on the ceiling outside bedroom #1. Facility states maintenance was notified of the damaged areas on 12/30/2024 and is scheduled to repair on 1/7/2025. LPA advised staff that the facility should be in good repair at all times for the health and safety of clients in care.

See LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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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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: RACHELLE'S HOME I
FACILITY NUMBER: 445202713
VISIT DATE: 12/31/2024
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LPA reviewed 9 out 9 Centrally Stored Medication and Destruction Records (CSMDRs). 9 out of 9 CSMDRs were observed to be complete with all medication documented.

Deficiencies were cited during today's visit per California Code of Regulations Title 22. See LIC809-D for more information. An exit interview was conducted with Office Manager Yuly Romero and a signed copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/22/2025 11:40 AM - It Cannot Be Edited


Created By: Marcella Tarin On 12/31/2024 at 10:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: RACHELLE'S HOME I
FACILITY NUMBER: 445202713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/01/2025
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by:
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Licensee states maintenance will be at the facility on 1/7/2025 to address the damaged flooring, damaged ceiling and damaged blinds bedroom #5 and dark sports on ceiling in bathroom #1. Licensee states the facility will conduct an in-service staff training by 1/10/2025, and submit documentation to CCL.
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LPA observed damaged flooring in the hallway outside bedroom #1, and damaged blinds in bedroom #5, and dark spots on the ceiling of bathroom #1, and water damaged areas on the ceiling outside bedroom #1 which poses a safety risk to clients in care.
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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.
SUPERVISOR'S NAME:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


LIC809 (FAS) - (06/04)
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