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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202876
Report Date: 06/07/2024
Date Signed: 06/07/2024 11:45:15 AM

Document Has Been Signed on 06/07/2024 11:45 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:
06/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Elizabeth BautistaTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted a case management visit for an exemption request for staff (S1) that cannot be completed due to incomplete information and incorrect form used. LPA met with Administrator (ADM) Elizabeth Bautista and stated the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) that serves individuals who are age 60 and over, approved for 6 non-ambulatory of which 1 may be bedridden and hospice waiver for 4.

LPA observed 5 out of 6 residents and 2 staff (S2 and S3), at the facility. 1 Out of 5 resident was in the living room watching TV, 1 Out of 5 is under hospice care, 3 out of 5 are in bed and resting. 1 out of 5 is out of the facility for medical appointment.

LPA checked Guardian S2 and S3 are both associated with the facility. LPA interviewed S2 and S3. and 4 out of 5 residents (R1 to R4).

LPA reviewed staff record and found that S1 worked at the facility since 5/7/2023 and no exemption transfer request was submitted to CDSS CPMB (Care Provider Management Branch).

Based on interview with S1, S2, and residents (R2 and R5) S1 works at the facility and provides care to residents. ADM stated that S1 has been working as a part time for the facility since 5/7/2023, and had an exemption from the old license that was closed on 8/23/2022. The exemption transfer approval for S1 was not transferred to the new license. ADM stated that he/she assumed that the exemption transfer approval of S1 from the old license is still effective after the closure of the old license.

Continuation on LIC 809-C, page 1 of 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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
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: 06/07/2024
NARRATIVE
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LPA discussed with ADM Title 22 CCR 87355 (e)(3) Criminal Record Clearance wherein, (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r) unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility

LPA discussed with ADM the importance of Title 22 CCR 87405 - Administrator Qualification (d)The administrator shall have the qualification as specified in Section 87405(d)(1) through (7). (2) Knowledge of and the ability to conform to the applicable laws, rules and regulations.

During visit, ADM started to work on the exemption transfer request for S1, filled the LIC 9188 and faxed the request to CPMB.

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 $500 for S1 working in the facility for more than 5 days without receiving criminal record exemption transfer approval. The civil penalty will be for $500 ($100 per day x 5 days = $500). See LIC421BG.

Failure to correct the cited deficiency, 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.

end of report
page 2 of 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/07/2024 11:45 AM - It Cannot Be Edited


Created By: Maria Partoza On 06/07/2024 at 10:53 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: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2024
Section Cited
CCR
87355(e)(3)

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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:(3)Request and be approved for a transfer of a criminal record exemption. This requirement is not met as evidenced by:
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ADM completed the LIC 9188 while LPA was in the facility and ADM stated that as soon as exemption transfer approval is received ADM will email or fax proof to LPA. ADM will fax the proof of application by POC due date.
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Based on interview and record review, S3 did not have an approved transfer of a criminal record exemption. S3 provides 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
06/08/2024
Section Cited
CCR87405(d)(2)

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87405 - Administrator Qualification (d) The administrator shall have the qualification as specified in Section 87405(d)(1) through (7). (2) Knowledge of and the ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by.
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ADM stated he/she will reference Title 22 at all times to ensure that ADM is complying with the regularions as applicable to the program. ADM will email LPA of the plan of correction by due date.
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Based on interview, ADM did not exhibit understanding of the applicable laws, rules and regulations by assuming that the exemption transfer approval from the old license automatically transfer to the new license.
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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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
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