<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202652
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:24:00 PM

Document Has Been Signed on 01/16/2025 02:24 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:COMPASSIONATE RESIDENTIAL CARE HOME INCFACILITY NUMBER:
435202652
ADMINISTRATOR/
DIRECTOR:		DEVANO, BELINDAFACILITY TYPE:
740
ADDRESS:2795 GEORGE BLAUER PLTELEPHONE:
(408) 238-8781
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 6CENSUS: 6DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Belinda DevanoTIME VISIT/
INSPECTION COMPLETED:
02:30 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 Analysts (LPAs) Christine (Dolores) Kabariti and Marcela Yanez arrived unannounced to conduct the facility's annual required - 1 year inspection. LPAs met with Administrator (ADM), Belinda Devano.

During visit, LPAs toured the facility with ADM to include the living room, resident bedrooms, staff bedroom, bathrooms, kitchen, garage, and backyard. There are 5 residents under hospice care.

All fire exit routes were free and clear of obstruction. 4 staff present are fingerprint cleared. 3 out of 4 staff are associated to the facility. 1 out of 4 staff present was fingerprint cleared but was not associated to the facility. During visit, the ADM associated the staff to the facility using Guardian. ADM was advised to ensure all staff are associated to the facility prior to work.

Facility temperature maintained at 72 degrees F. Fire extinguisher last serviced on 06/04/2024. Carbon monoxide detector observed present and operable in the hallway next to the kitchen. Smoke detectors observed throughout the facility. First aid kit observed complete. LPA observed Personal Protective Equipment (PPE) supplies. Emergency lighting such as lanterns and flashlights observed in the facility. Facility is conducting fire drills quarterly and the last drill was completed on 01/03/2025.

5 out of 5 resident bedrooms observed equipped with proper furniture and lighting to include a bed, linens, night stand, and dresser. 4 out of 5 resident's who are under hospice observed with full bed rails. Based on record review, 4 out of 5 residents hospice care plan included the physician order for full bed rails. 2 residents used oxygen. Oxygen in use sign observed posted outside the resident bedrooms. See LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: COMPASSIONATE RESIDENTIAL CARE HOME INC
FACILITY NUMBER: 435202652
VISIT DATE: 01/16/2025
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
26
27
28
29
30
31
32
Around 11:20AM, the hot water temperature was measured in the bathroom next to bedroom #1 to be maintained at 102 degrees F. ADM states the hot water temperature is low because in the morning they use a lot of hot water. ADM states the hot water should raise in the afternoon. At 1:30PM, the hot water temperature was measured at 121.8 degrees F. Bathroom showers are equipped with grab bars and non-slip mats.

Sharp objects, chemicals/toxins, and medications observed locked. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature in the kitchen measured at 34 degrees F. Freezer temperature in the kitchen measured at 0 degrees F. There are 2 additional refrigerators in the garage which stores more food for the residents. The refrigerator in the garage temperatures measured at 40 degrees F and freezer measured at 0 degrees F.

3 resident files were reviewed. 1 out of 3 resident files did not contain an appraisal/needs and services plan. ADM was unable to produce the appraisal/needs and services plan for the 1 resident. 2 out of 3 resident files contained an appraisal/needs and services plan. 3 resident files reviewed were up to date and maintained. 3 residents centrally stored medications and records were reviewed and all medications were accounted for. 2 residents were interviewed.

3 staff records were reviewed and observed complete and maintained. 3 out of 3 staff annual training were complete to include at least 20 hours of annual training.

Posters observed to include but not limited to the ombudsman, complaint poster, theft and loss policy, admission agreement, and house rules.

Documents were obtained to update the facility's file to include: LIC500, LIC308. LIC400, Liability insurance, proof of administrator certificate renewal, and page 9 of the emergency disaster plan. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note provided. This report was reviewed with Administrator, Belinda Devano and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/16/2025 02:24 PM - It Cannot Be Edited


Created By: Christine Dolores On 01/16/2025 at 02:02 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: COMPASSIONATE RESIDENTIAL CARE HOME INC
FACILITY NUMBER: 435202652

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(E)
(b) Each resident’s record shall contain at least the following informationn: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review the licensee did not comply with the section cited above wherein 1 resident's file did not contain an appraisal/needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
1
2
3
4
Licensee will complete an appraisal/needs and services plan for the 1 resident and will ensure the resident's POA (power of attorney) will sign the form. Licensee will send LPA (Dolores) Kabariti the signed appraisal/needs and services plan via email by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4