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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202862
Report Date: 07/17/2025
Date Signed: 07/17/2025 01:21:41 PM

Document Has Been Signed on 07/17/2025 01:21 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:HANSELL VILLAFACILITY NUMBER:
435202862
ADMINISTRATOR/
DIRECTOR:		ELIZABETH BAUTISTAFACILITY TYPE:
740
ADDRESS:5343 HANSELL DRIVETELEPHONE:
(408) 362-9195
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
07/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Elizabeth Bautista, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Elizabeth Bautista, Administrator. LPA announced the purpose of the visit. LPA observed 2 staff and 4 residents, 1 resident is currently hospitalized.

During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days.

LPA observed a garage with laundry area and separate pantry for residents and staff food storage. LPA observed a staff lounge area for staff to use on breaks and lunches.

LPA toured 4 resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights.

ADM tested the smoke detector in the hallway and found to function properly when tested. The facility has a pull fire alarm last serviced on 05/16/25 LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 118-119 degrees F.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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: HANSELL VILLA
FACILITY NUMBER: 435202862
VISIT DATE: 07/17/2025
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LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 03/15/2024. LPA reviewed Fire and Earthquake log. The Facility last disaster drill was last conducted on 05/30/25

LPA reviewed resident records for 3 out of 4 residents.. LPA reviewed 3 staff records. ADM and LPA reviewed Centrally Stored Medication Record for 3 residents.

During visit LPA observed R1 medication record was not update from 01/16/25 which poses an immediate health and safety risk for resident in care. ADM did not report R1s refusal of medication to the department within 7 days of occurrence. ADM stated resident has been refusing medication (Tam) since it was prescribed on 03/28/25.

Deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Elizabeth Bautista and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Marcela Yanez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2025 01:21 PM - It Cannot Be Edited


Created By: Marcela Yanez On 07/17/2025 at 12:28 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: HANSELL VILLA
FACILITY NUMBER: 435202862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)

87465 Incidental Medical and Dental Care (h)(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not mainitaining an accurate and current record of R1s medication list which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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ADM stated she will write a letter of understanding of regulation and submit to the department a record of the current medications R1 is currently taking prescribed by physicians.
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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Marcela Yanez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2025 01:21 PM - It Cannot Be Edited


Created By: Marcela Yanez On 07/17/2025 at 12:46 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: HANSELL VILLA
FACILITY NUMBER: 435202862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)(D)

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency... including, (1) A written report shall be submitted to the licensing agency ... within seven days ...(D)Any incident which threatens the welfare, safety or health of any resident ...
The requirement was not met as evidenced by:
Deficient Practice Statement
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Based on the records reviewed, the facility did not send the incident report of resident R1 refusing to take medication within 7 days of the incident occurrence, this poses a potential health, safety risk to persons in care. R1 has refused to take medication since prescribed on 3/28/25.
POC Due Date: 07/24/2025
Plan of Correction
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ADM stated they will submit a written report for a R1 refusal of medication to the department for every occurance and notify the POA and Doctor of each refusal, and ADM will submit letter of understanding for the regulation emailed to LPA by POC due 07/24/25
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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Marcela Yanez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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