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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200608
Report Date: 10/26/2022
Date Signed: 10/26/2022 04:58:16 PM

Document Has Been Signed on 10/26/2022 04:58 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:MAYFLOWER CARE HOMEFACILITY NUMBER:
435200608
ADMINISTRATOR:ESLAVA, ISABEL M.FACILITY TYPE:
740
ADDRESS:668 APACHE COURTTELEPHONE:
(408) 972-1999
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: DATE:
10/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:Isabel EslavaTIME COMPLETED:
05:03 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management visit. LPA met with facility administrator Isabel Eslava (Admin).

LPA arrived at the facility to deliver findings on an unsubstantiated complaint investigation. While reviewing financial records as they pertained to the complaint investigation,The Department found that the facility financial files indicated that during the period of July 1, 2019 through June 30 2021 the licensee maintained an average cash reserve that was low compared to facility’s average monthly operating cost. Cash reserves should be increased to meet 1 month’s average operating costs, at minimum.

Deficiency cited, see 809-D. This report was reviewed with facility administrator Isabel Eslava and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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 10/26/2022 04:58 PM - It Cannot Be Edited


Created By: Ryker Heberle On 10/26/2022 at 03:25 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: MAYFLOWER CARE HOME
FACILITY NUMBER: 435200608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2022
Section Cited
CCR
87213

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87213 - Finances - The licensee shall have a financial plan that conforms to the requirements of Section 87155... and that assures sufficient resources to meet operating costs for care of residents... This requirement was not met as evidenced by:
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Facility to provide quarterly financial statements for the year 2022 to licensing by the POC due date.
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Based on records review, the facility did not have adequate cash reserves to meet 1 month's average operating costs. This posed a potential threat to the health and safety of residents 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:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022


LIC809 (FAS) - (06/04)
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