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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200786
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:16:24 AM

Document Has Been Signed on 01/26/2023 11:16 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:MERTZ CARE HOME IIIFACILITY NUMBER:
435200786
ADMINISTRATOR:JIMENEZ, Y. ROGELINEFACILITY TYPE:
740
ADDRESS:3928 THAINWOOD WAYTELEPHONE:
(408) 532-7020
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 1DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Administrator Rogeline JimenezTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Simi Rai and LPA Manuel Monter conducted an unannounced annual inspection focusing on infection control. LPAs met with Administrator Rogeline Jimenez. There are zero residents at the facility and 2 staff including Administrator were observed. 1 resident is at Adult Day Program.
During visit, LPAs toured the facility to include the 1 living room, 3 resident rooms, 2 bathrooms, 1 staff room, kitchen, laundry area, dining area, garage and exterior. All fire exit routes are free and clear of obstruction. Toxins and sharp objects were secured. Medication stored in a locked cabinet.
Facility observed to have a designated central entry point to include a sign-in sheet and temperature check. Facility clean and disinfect twice daily and as often as needed. Bathrooms supplied with hygiene products and hand washing sign. Trash can with lid observed. LPAs observed a sufficient amount of Personal Protective Equipment (PPE). The following posters observed to include wash your hands, symptoms of COVID-19, importance of wearing a mask, and donning and doffing PPE.

During visit, the administrator will provide the following documents to updated facility file by 2/2/2023 and other required documents but not limited to:
  • LIC610E Emergency Disaster Plan
  • LIC500 Personnel Summary
  • LIC308 Designated of Administrator
  • LIC400 Affidavit of Cash Resources
  • RCFE Administrator Certification
  • Liability Insurance

No deficiencies were cited per California Code of Regulations, Title 22. A Technical Assistance Note was provided. This report was reviewed with Administrator Rogeline Jimenez and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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