435200608-10-13-2025-26-AS-MPAA-DMEQBR-20251013120158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200608
Report Date: 10/13/2025
Date Signed: 10/13/2025 12:02:43 PM

Document Has Been Signed on 10/13/2025 12:02 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 HOME		FACILITY NUMBER:	435200608
ADMINISTRATOR/ DIRECTOR:	ESLAVA, ISABEL M.		FACILITY TYPE:	740
ADDRESS:	668 APACHE COURT		TELEPHONE:	(408) 972-1999
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 6		CENSUS: 6	DATE:	10/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Isabel M. Eslava		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required 1 year inspection visit, met with Administrator Isabel Eslava and stated the purpose of the visit. The facility is licensed to serve adults 60 and over, 5 non-ambulatory and 1 bedridden. The facility has 2 hospice waiver. LPA toured the facility with ADM, inside and outside including but not limited to the kitchen, dining, 4 resident bedrooms, 2 staff room, 2 bathrooms used by the resident and staff and laundry area. Bathroom are equipped with grab bars and anti slip mats. LPA observed 6 bedrooms, 4 Out of 6 bedrooms are used by resident and 2 Out of 6 bedroom are used by staff. 6 Out of 6 bedrooms have functioning lights, a chair, clean bedding, storage space for personal belongings of residents. 1 Out of 6 resident is under hospice care, 3 out of 5 are non-ambulatory and 2 Out of 6 are ambulatory. 2 Out of 6 bedroom are shared and 4 out of 6 are not shared. LPA observed the laundry area and chemicals are locked and inaccessible to persons in care. LPA observed that the dining room and kitchen are organized and sanitary. LPA observed 2 days of perishable food and 7 days of non-perishable food. LPA observed the sharps and chemicals are stored in a locked cabinet under the sink. The medication cabinet is locked and inaccessible to residents. page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 435200608
	VISIT DATE: 10/13/2025

NARRATIVE

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LPA observed 2 double door refrigerators/freezer combination and temperature measured at 32 degree F and 0 degree F. The facility temperature measured at 71 degree F, the water temperature measured at 112.1 degree F.

LPA observed that interior hallways, and exterior walkways are not obstructed and free from debris. However, LPA observed that facility has excessive incontinent supply stored in different places of the facility such as the shed, garage, and near the emergency exit area. LPA observed unused wheelchairs, more incontinent supplies and construction materials piled on one side by the fence of the backyard. LPA observed 2 locked storage shed in the exterior of the facility. LPA observed that the ramps and railings around the facility are sturdy and maintained. LPA observed emergency exit doors/sliding doors are working and free from obstruction.

The facility is equipped with carbon monoxide and smoke alarm system, in good working condition when tested. The facility is equipped with a fire extinguisher last inspected on 05/08/25. The facility conducted their fire/earthquake and disaster training drill was on 01/12/25, 03/02/25, 07/06/25 and 09/03/25.

LPA reviewed 3 out of 4 staff record. LPA verified that 3 Out of 4 staff are fingerprint and criminal background cleared. Training are updated and health screening are cleared. LPA reviewed 3 out of 6 resident and verified them to be complete and up to date.

No deficiencies were cited during today's inspection based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Administrator Isabel Eslava and a copy of the report was provided.

end of report
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025

LIC809 (FAS) - (06/04)

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