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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201082
Report Date: 10/15/2024
Date Signed: 10/15/2024 04:37:44 PM

Document Has Been Signed on 10/15/2024 04:37 PM - 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:A & T CARE HOMEFACILITY NUMBER:
435201082
ADMINISTRATOR/
DIRECTOR:		NGO, ALLISONFACILITY TYPE:
735
ADDRESS:1768 VIA FLORES COURTTELEPHONE:
(408) 956-1484
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 6DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:S1 Flordeliza RavaneraTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Marcela Yanez and Manuel Monter conducted an unannounced Required 1 Year visit and met with Staff S1 Flordeliza Ravanera. S1 contacted ADM, who stated she could not come to the facility and S1 could sign the report in her stead.

During visit, LPAs toured the facility inside and out. LPA toured the garage area and observed it being used as a laundry and storage area. LPA's also observed food storage areas. LPAs observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days.

LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. S1 tested the smoke detectors and found the smoke detector to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 105 degrees F.

While touring the backyard LPA observed the ramp from the bonus room connecting to the backyard. When LPAs stepped on floorboard of the ramp, it sunk when stepped on.

LPA's also observed the ramp in the backyard connecting to bedroom #2 the hand rail of the ramp was broken and loose. (Photograph was taken.)
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: A & T CARE HOME
FACILITY NUMBER: 435201082
VISIT DATE: 10/15/2024
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LPA's also observed a shed in the backyard, inside shed was storage for facility and locked. LPA toured the outside area and found the exits to be clear of obstructions.

LPA observed fire extinguishers in kitchen and garage both was last serviced on 07/16/2024 LPA reviewed Fire and Earthquake log was last drill was on 08/31/2024

LPA randomly reviewed 3 resident records and 3 staff records. LPAs reviewed 3 residents P&I records

Deficiency is being cited as per California Code of Regulations Title 22. This report was reviewed with Staff S1, and facility ADM was contacted via phone call. and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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Document Has Been Signed on 10/15/2024 04:37 PM - It Cannot Be Edited


Created By: Marcela Yanez On 10/15/2024 at 03:58 PM
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: A & T CARE HOME
FACILITY NUMBER: 435201082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed the ramp connecting to room #2 and backyard had its hand rail damaged. LPAs also observed ramp connecting bonus and backyard had floor boards sunk when stepped on. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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ADM stated she will submit a written plan of action on how she will fix the issues noted on the ramp and hand rails. ADM stated she will send photo documentation showing the floorboards and handrail are in good repair. ADM stated she will send the Plan of Correction by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


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