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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202854
Report Date: 01/23/2025
Date Signed: 01/23/2025 04:38:40 PM

Document Has Been Signed on 01/23/2025 04:38 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:CAMBRIAN SENIOR LIVINGFACILITY NUMBER:
435202854
ADMINISTRATOR/
DIRECTOR:		AZAREL JAMES EQUINGFACILITY TYPE:
740
ADDRESS:3520 MAY LANETELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 6DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:James EquingTIME VISIT/
INSPECTION COMPLETED:
04:12 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with Administrator (ADM) James Equing .

License, Personal Rights posters, and Administrator Certificate were observed at entrance. LPA observed 4 staff and 6 residents in the facility. LPA reviewed 3 residents files (R1 - R3) and 3 staff files (S1 - S3). 2 Out of 3 residents (R1 and R3) centrally stored medication forms were observed not matching with their medication counts.

LPA toured the facility with ADM inside and out. LPA inspected living room, kitchen, dining area, 2 sitting areas, and laundry room. There are 6 single rooms for residents, and one staff live-in room in facility. 3 bathrooms were inspected. Two days perishable foods and seven nonperishable foods were observed sufficient. The temperature of the refrigerator was observed at 16 degree F, and the temperature of the freezer was observed at -1 degree F. Room temperature was observed at 72 degree F. Hot water was observed at 117 degree F. Medication cabinet, and knife closet, were observed locked. Dish washing solution bottle was observed on the top of sink in the kitchen, ADM locked the dish washing solution bottle in the closet under the sink immediately. ADM stated staff just finished using the dish washing solution after lunch.

LPA checked the call bell system in resident rooms and it was functional. Door alarms were observed installed at the exit doors. First Aid box, flash lights, and night lights were observed in the facility.

LPA observed 6 beds in the resident rooms with half bed rails. ADM provided 6 residents' physician reports. 1 Out 6 residents is on hospice care, and 5 Out of 6 residents having physician orders for using half bed rail.
Continue on LIC809-C.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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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: CAMBRIAN SENIOR LIVING
FACILITY NUMBER: 435202854
VISIT DATE: 01/23/2025
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The facility's last time conducted the fire drill was on 1/7/2025. Front yard and back yard were inspected. LPA observed a tree's branches blocked half of the walkway to the exit. Staff trimmed the tree branches before LPA completed the visit. No obstruction was observed to block the walkway after staff had trimmed the tree..

Deficiency noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 04:38 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 01/23/2025 at 03:29 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: CAMBRIAN SENIOR LIVING
FACILITY NUMBER: 435202854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(1)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 2 Out 3 residents' centrally stored medication forms were observed not matching with their count of medication, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Administrator stated to submit plan of correction by the POC due date to ensure residents' centrally stored medication forms were well maintained. Administrator stated the facility will provide staff taring for medication and to submit the staff training log.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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