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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202876
Report Date: 05/24/2024
Date Signed: 05/24/2024 11:44:01 AM

Document Has Been Signed on 05/24/2024 11:44 AM - 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:FAMILY SENIOR CARE HOME IFACILITY NUMBER:
435202876
ADMINISTRATOR/
DIRECTOR:		BAUTISTA, ELIZABETHFACILITY TYPE:
740
ADDRESS:2898 GLEN FROST COURTTELEPHONE:
(408) 802-7727
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 6DATE:
05/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Administrator, Elizabeth BautistaTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai is conducting a case management visit as a result of finding information during today's complaint investigation. LPA Rai met with Administrator (ADM) Elizabeth Bautista. LPA Rai observed 5 residents and 2 staff at the facility. During today's visit, LPA Rai observed Staff (S3) leave the facility as his/her shift was ended. S3 was not associated to the facility.

During LPA's investigation interviews with S1 and S2, S1 and S2 were not associated to the facility. S1 and S2 stated they both started working on Saturday, May 18th, 2024. S1 and S2 stated they provide care and supervision to the residents, such as but not limited to assisting residents with feeding, bathing, grooming, and incontinence care.

LPA Rai verified S1 and S3 do have a California criminal record clearance but are not associated to the facility. ADM stated S2 does not have California criminal record clearance because S2 is shadowing the care staff and will be leaving the facility tomorrow. ADM stated S1 and S3 are care staff and provide care and supervision to the residents at the facility.

LPA Rai educated ADM on Title 22 CCR 87355 Criminal Record Clearance wherein all individuals prior to working, residing or volunteering at the facility need to have a California criminal record clearance and ensure they are associated to the facility.

During visit, Administrator signed up on Guardian to set up an account to be able to associate and disassociate individuals who are working, residing or volunteering at the facility.

Continuation on LIC 809-C, page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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 3
Document Has Been Signed on 05/24/2024 11:44 AM - It Cannot Be Edited


Created By: Simranjit Rai On 05/24/2024 at 10:24 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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2024
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ... prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
This requirement is not met as evidenced by:
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Administrator stated staff S2 will be removed from the facility and will return after obtaining a Claifornia criminal record clearance. Administrator stated to submit a written plan of action and understanding regulations by POC dute date. Administrator agreed and understood.
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Based on observation, interview and record review, staff S2 did not have a California Criminal Record Clearance and S2 was providing care and supervision to the residents at the facility which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
05/25/2024
Section Cited
CCR87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ... prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance.
This requirement is not met as evidenced by:
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Administrator stated she will ensure staff S1 and S3 will ensure the California criminal record clearance is transferred and associated to the facility. Administrator stated to submit a written plan of action and understanding regulations by POC dute date. Administrator agreed and understood.
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Based on observation, interview and record review, staff S1 and S3 did have a California Criminal Record Clearance but was not assosicated to the 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: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876
VISIT DATE: 05/24/2024
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Page 2 of 2.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809-D. A civil penalty is being assessed for the amount of $1500. For S2 working in the facility for more than 5 days without receiving a California criminal record clearance, the civil penalty will be for $500 ($100 per day x 5 days = $500). For S1 and S3 working at the facility without associate and California criminal record clearance transfer, the civil penalty will be $1000 ($100 per day x 5 days = $500 for two individuals). See LIC421BG.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator Elizabeth Bautista and a copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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