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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202446
Report Date: 07/11/2024
Date Signed: 07/11/2024 09:36:44 AM

Document Has Been Signed on 07/11/2024 09:36 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:MAYWOOD MANOR LLCFACILITY NUMBER:
435202446
ADMINISTRATOR/
DIRECTOR:
ELVIRA C. CASIMFACILITY TYPE:
735
ADDRESS:3071 PRUNERIDGE AVENUETELEPHONE:
(408) 802-9105
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 6CENSUS: 5DATE:
07/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Staff (S1) Jacob Jr GarabiagTIME VISIT/
INSPECTION COMPLETED:
09:40 AM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit at the facility to clear the Type A deficiency cited on 6/21/2024. LPA Rai met with staff (S1) Jacob Jr Garabiag and stated the purpose of today's visit. LPA Rai observed 2 staff (S1&S2) and 1 resident (R1) at the facility, 4 residents were attending day program. This facility is a level 4f and 5 out of 5 residents are Developmentally Disabled overseen by the San Andreas Regional Center.

During visit, LPA Rai toured the facility and checked all resident rooms. LPA Rai observed resident rooms were locked. Staff (S2) unlocked all resident rooms included R1's room. S2 stated all the rooms are locked and R1 was waiting to go to day program. LPA Rai was not able to get a hold of Administrator, Elvira Casim over the phone and left her a message.

LPA Rai spoke with Staff S1 and S2 and stated the resident rooms can be locked if the residents also have a key to their room and R1 did not have a key. LPA Rai understands that 4 out of 5 residents had left for the day program and R1 was waiting for transportation to the day program. LPA Rai advised staff that when residents are present in the facility, they need to have access to the room, either they have a key or the bedroom doors remained unlocked. Staff S1 and S2 agreed and understood.

LPA Rai observed the storage room is being used as storage and not a bedroom. LPA Rai observed boxes of items, a rack filled with shoes and a cabinet filled with items. S1 and S2 stated no one sleeps in the storage room and S2 now lives out of the facility.

Letter of Deficiency Citations Cleared and was provided to S1 during today's visit.

No deficiencies were cited during today's visit. Technical Violation was provided. Exit interview was conducted with staff (S1) Jacob Jr. Garabiag and a copy of this report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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