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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200608
Report Date: 07/31/2023
Date Signed: 07/31/2023 04:07:54 PM

Document Has Been Signed on 07/31/2023 04:07 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: 5DATE:
07/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:34 PM
MET WITH:Administrator Isabel EslavaTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPA) David Marrufo and Manuel Monter conducted an unannounced case management visit. The reason for the case management visit is due to an incident report that the facility submitted on 7/25/23. LPA's met with Administrator (ADM) Isabel Eslava.

On 7/25/23, the department received an incident report stating that resident (R1) had left the facility at 5:30pm on 7/21/23. Staff waited till midnight but the resident did not return. Incident report states that the staff contacted 911 on 7/26/23. The Incident Report states that R1's conservator contact the facility to let them know that R1 had checked themselves in to Emergency psychiatric services (EPS). The incident report also states that EPS provided a sexual assault rape kit for R1.

LPA's reviewed facility records. R1's physicians report that states, R1 is able to leave the facility unassisted. LPA's reviewed admission agreement, including house rules. LPA's reviewed the facility's care giver report regarding R1's previous elopement at this facility on May 23rd 2023. LPA's reviewed facility personnel report. LPA's reviewed R1's Medication Records for the month of July.

LPA's interviewed ADM, Staff S1 and S2. S2 was staff member on duty at the facility when resident R1 eloped on 7/21/23.

No deficiencies cited during todays visit. A copy of the report was provided to ADM Isabel Eslava.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2023
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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