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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202834
Report Date: 03/06/2024
Date Signed: 03/06/2024 04:25:11 PM

Document Has Been Signed on 03/06/2024 04:25 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:ANDREA'S ELDERLY CARE FACILITY #2FACILITY NUMBER:
435202834
ADMINISTRATOR:ROQUE, PERCIVALFACILITY TYPE:
740
ADDRESS:1525 FRANKLIN ST.TELEPHONE:
(408) 605-2033
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 6CENSUS: 6DATE:
03/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Back-Up Administrator/Lead Staff, Lerma Espiritu TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an case management visit to address information obtained during today's complaint investigation visit. LPA Rai met with Back-Up Administrator/Lead Staff, Lerma Espiritu and stated the purpose of the visit.

During today's visit, LPA interviewed staff (S2). S2 was not associated to the facility as of 3/5/2024. Upon further investigation, S2 has a California criminal record clearance and is associated to another licensed facilty but is not associated to this facility. Per interview with S2, S2 did work with the facilty before and left around 2020, but came back to work with the residents as a caregiver in June/July 2023. S2 did confirm to work at the facility January 2024 - March 2024.

Back-Up Administrator/Lead Staff and LPA Rai reviewed S2's staff file and did observe LIC 9182 Criminal Background Clearance Transfer Request made in 2019 to transfer S2's criminal record clearance to the facility. Per Guardian, S2 was separated from the facility in 2020. Back-Up Administrator/Lead Staff stated the facility did not transfer S2's criminal record clearance when S2 returned to work at the facility in 2023. Back-Up Administrator/Lead Staff, Lerma Espiritu stated the facility will transfer S2's criminal record clearance to the facility tonight 3/6/2024.

A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S2) working at the facility without a Criminal Background clearance transfer. Please see LIC 421BG.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Back-Up Administrator/Lead Staff, Lerma Espiritu. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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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Document Has Been Signed on 03/06/2024 04:25 PM - It Cannot Be Edited


Created By: Simranjit Rai On 03/06/2024 at 03:46 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: ANDREA'S ELDERLY CARE FACILITY #2
FACILITY NUMBER: 435202834

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c).
This requirement is met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and will ensure S2 is associated to the facility by POC due date. Administrator agreed and understood.

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Based on interview and record review, staff (S2) has obtain a California clearance but criminal record clearance has not been transferred to this facility, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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