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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202443
Report Date: 04/04/2024
Date Signed: 04/04/2024 11:17:05 AM

Document Has Been Signed on 04/04/2024 11:17 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:MLJ CARE HOMEFACILITY NUMBER:
435202443
ADMINISTRATOR/
DIRECTOR:		LOLITA R. BAUTISTAFACILITY TYPE:
735
ADDRESS:2882 SCOTTSDALE DRIVETELEPHONE:
(408) 238-2949
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
04/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Lead Staff, Sheryll GranilTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit and met with Lead Staff, Sheryll Granil. LPA Rai stated the purpose of today’s visit to assess the facility’s request for an exception for R1’s prohibited condition.

During visit, LPA Rai observed 2 staff in the facility, including Lead Staff, Sheryll Granil.

The licensee has submitted an exception request for R1 who is dependent on others to perform all activities of daily living. Staff were interviewed concerning R1's care and the requirement of the exception. R1 is not receiving Hospice services at this time.

At approximately 10:58am, LPA Rai observed R1 in a laying position in bed. R1 was awake and LPA Rai attempted to conduct an interview but R1 did not respond to questions. R1 was not able to move arms, legs or hands. R1 was observed with contractures in the hands and R1 was unable to grab items such as a glass of water or hairbrush. LS stated the facility staff provide assistance to R1 in all areas of activity of daily living.

At this time, the Department is reviewing Licensee's request for the exception for R1. LPA Rai requested for R1’s LIC 9172 Functional Capability Assessment dated 10/26/2023.

No deficiencies were cited. Exit interview conducted with Lead Staff, Sheryll Granil. A copy of this report was
provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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