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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708150
Report Date: 05/24/2023
Date Signed: 05/24/2023 04:18:08 PM

Document Has Been Signed on 05/24/2023 04:18 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:COLLEGE MANORFACILITY NUMBER:
430708150
ADMINISTRATOR:CORA REYESFACILITY TYPE:
740
ADDRESS:760 LEIGH AVENUETELEPHONE:
(408) 293-3745
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 6DATE:
05/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Dominca OlivaTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to continue a complaint investigation and during visit a case management – deficiencies visit was conducted due to a violation observed. LPA met with Licensee, Dominica Oliva.

During visit, LPA toured the facility to include the living room, kitchen, resident rooms, bedrooms, staff bedrooms, and exterior. During tour, it was found staff (S1) is residing and working in the facility without obtaining a fingerprint clearance. S1 began work in February 2023. Licensee was unable to produce S1’s clearance letter from the Department. LPA observed S1's letter from the Department of Justice. S1 was asked to leave the facility. Licensee was informed S1 cannot return to work and reside in the facility without obtaining a fingerprint clearance. Licensee stated understanding.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S1) working and residing at the facility without fingerprint clearance. Please see LIC 421BG.

This report was reviewed with Licensee, Dominica Oliva and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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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Document Has Been Signed on 05/24/2023 04:18 PM - It Cannot Be Edited


Created By: Christine Dolores On 05/24/2023 at 03:21 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: COLLEGE MANOR
FACILITY NUMBER: 430708150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2023
Section Cited
CCR
87355(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or ... This requirement was not met as evidenced by:
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Staff (S1) was asked to leave the facility. Licensee was informed S1 cannot reside or work in the facility until a fingerprint clearance has been obtained. Licensee will submit a written plan to LPA by POC due date.
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Based on record review, interview, and observation the Licensee did not comply with the section cited above for staff (S1) working and residing in the facility without fingerprint clearance which poses an immediate health, safety, and personal rights risk to persons 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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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