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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202146
Report Date: 11/20/2023
Date Signed: 11/20/2023 04:45:05 PM

Document Has Been Signed on 11/20/2023 04:45 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:RENFIELD RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202146
ADMINISTRATOR:MADONNA O. DUMANTAYFACILITY TYPE:
735
ADDRESS:2389 RENFIELD WAYTELEPHONE:
(408) 223-0754
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
11/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Lead Staff Leonardo MartinezTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Simi Rai conducted a case management visit while facility was being inspected for pre-licensing visit for Manfred Care Home LLC. LPA met with Lead Staff Leonardo Martinez.

LPA Rai spoke with Administrator to obtain verbal authorization for Lead Staff Leonardo Martinez to review and sign the report on ADM's behalf.

LPA Rai observed 3 residents in the living room and activity room and 3 staff members present in the facilty.

During today's visit, LPA Rai conducted further investigation on deficiencies observed on 10/26/2023.

The following deficiencies were cleared during today's visit.

For regulation CCR 85087(a)(3)(A), LPA Rai observed the garage area. LPA Rai did not observe a bed or any elements of staff or residents using the garage as a living space. LPA Rai observed a table in the middle of the garage and staff S1 stated the space is being used a break room and no one is sleeping in the garage. Training was provided to the staff as Administrator stated in the Plan of Correction (POC).

For regulation CCR 80020(a), LPA Rai observed the backyard space. LPA Rai did not observe shed in the backyard. The space is not being occupied with a shed and there is a bench that replaced the habitual shed. There are no signs of the habitual shed in the backyard. The habitual shed has been removed as Administrator stated in the Plan of Correction (POC).

Based on today's inspection visit, the Administrator and staff have corrected all of the above citation/deficiencies. Plan of Correction (POC) clearance is issued and provided to Lead Staff Leonardo Martinez. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Lead Staff Leonardo Martinez and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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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