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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201229
Report Date: 12/08/2025
Date Signed: 12/08/2025 02:21:23 PM

Document Has Been Signed on 12/08/2025 02:21 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:LOVELY CARE HOMEFACILITY NUMBER:
435201229
ADMINISTRATOR/
DIRECTOR:		ELIZA DAQUIOAGFACILITY TYPE:
740
ADDRESS:3640 HEATHCOT COURTTELEPHONE:
(408) 531-9515
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
12/08/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator / Licensee Eliza DaquioagTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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An informal meeting was conducted today at the San Jose Adult and Senior Care Regional office. Present in the meeting was Licensing Program Manager (LPM) Romeo Manzano, LPM Christine Kabariti, Licensing Program Analyst (LPA) Manuel Monter, Administrator / Licensee Eliza Daquioag

During the meeting, LPM discussed the informal meeting process as a course of action for the facility to achieve compliance with Title 22 Regulations. The administrative action process was discussed by LPM.

This informal meeting was initiated due to a recent serious violation issued to the facility at the conclusion of a complaint investigation (26-AS-20250710151220), regarding the allegation facility staff restrained resident. During office visit, deficiencies were discussed.

LPA and LPM requested the facility ADM provide an action plan to discuss the following, Due 12/22/2025:
  • Ensure resident's personal rights are not violated and residents are not restricted in their movement.
  • How the facility staff will be trained in dealing with the many types of behaviors related to residents with neurocognitive disorder associated with behaviors such combativeness, confusion in the facility.
  • How the facility will ensure residents appraisals are updated in writing as frequently as necessary to note significant changes in condition and to keep the appraisal accurate.
  • How the facility shall be trained regarding personal rights and reporting requirements.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2025
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: LOVELY CARE HOME
FACILITY NUMBER: 435201229
VISIT DATE: 12/08/2025
NARRATIVE
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During this office visit, LPM's and LPA's informed Licensee, the complaint dated July 10, 2025, 26-AS-20250710151220, to amend findings for the allegation: Facility is not meeting the hygiene needs of residents in care, from Substantiated to Unfounded, due to additional information

The Department inadvertently did not issue Title 22 code of regulation, 87468.1 Personal Rights of Residents in All Facilities(a)(1), on August 22, 2025.

RO provided PIN 22-24-ASC Collaborating With Home Health Agencies and Hospice Agencies To Provide Care To Residents

RO provided the Licensees information regarding the Department’s technical support program (TSP) and provided a TSP brochure, Community Care Licensing Division (CCLD) website www.cdss.ca.gov

The Licensee was advised a the end of the office meeting that non-adherence to the plan will result in a
non-compliance conference.

Deficiencies are being cited during this meeting, see LIC809-D. This report was reviewed and explained to Administrator / Licensee Eliza Daquioag. Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/08/2025 02:21 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/08/2025 at 10:01 AM
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: LOVELY CARE HOME
FACILITY NUMBER: 435201229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2025
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities(a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by:
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ADM stated the facility will not use multiple diapers on the resident. ADM stated if a resident is being combative, staff will give resident time to calm down and redirect his/her behaviors. ADM stated she shall provide training to staff training regarding personal rights.
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Based on interviews conducted, facility staff S1-S3 and ADM admitted to putting multiple diapers on resident R1 and R2. S1, S2 and ADM admitted that R1 feet were tied. This poses an immediate threat to residents health, safety and personal rights.
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ADM stated will consult medical doctor to address behavior. ADM stated she will submit the written plan of correction to LPA by POC due date, December 9, 2025.

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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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2025


LIC809 (FAS) - (06/04)
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