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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202885
Report Date: 03/12/2025
Date Signed: 03/12/2025 01:03:55 PM

Document Has Been Signed on 03/12/2025 01:03 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:MERIDIAN VILLAFACILITY NUMBER:
435202885
ADMINISTRATOR/
DIRECTOR:
ROSANA MENDOZAFACILITY TYPE:
740
ADDRESS:2755 MERIDIAN AVETELEPHONE:
(408) 440-2445
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 6DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Rosana Mendoza, ADMTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On March 12, 2025, at 10:30 AM, Licensing Program Analyst (LPA) Kenneth Madrigal and Steve Chang conducted an unannounced annual inspection visit, and met with Rosana Mendoza, Administrator (ADM). Upon arrival, Staff 1 (S1) identified themselves and LPAs were granted access to the facility as LPAs explained the purpose of the visit.

During the entrance of the inspection, LPAs observed 6 residents and 2 staff. LPA toured the facility inside out with ADM which included the living room, kitchen, dining room, restrooms, residents’ bedrooms, and staff areas. Upon entrance, the facility has personal rights, ADM certificate, resident council, hospice waiver, designation of facility responsibility, the facility licensee, and the emergency disaster plan. The front yard and backyard were inspected. Two-day perishable food supplies and seven-day nonperishable food supplies were observed. LPA observed the cleaning product and knifes storage area is locked and inaccessible to residents in care. The facility room temperature was at 72 degrees F, the fridge was measured at 32 degrees F, the freezer was measured at 0 degrees F and hot water temperature was measured at 105 degrees F in both resident bathrooms.

A new fire extinguisher was purchased on March 9, 2025. The facility was equipped with smoke and carbon monoxide detectors and were tested by ADM. LPA observed facility first aid kit. LPAs reviewed 3 staff record files and 3 resident file records.

Deficiency noted today based on LPA observations, interviews conducted and record reviews in accordance with the California Code of Regulations (CCR) Title 22, Division 6. See LIC 809-D.

An exit interview was conducted with ADM. This Evaluation Report was reviewed with Rosana Mendoza, Administrator. A copy of the signed report and Appeal Rights was provided to ADM.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Kenneth Madrigal
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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Document Has Been Signed on 03/12/2025 01:03 PM - It Cannot Be Edited


Created By: Kenneth Madrigal On 03/12/2025 at 12:51 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: MERIDIAN VILLA

FACILITY NUMBER: 435202885

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/12/2025

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

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 that R1's centrally stored medication form does not match R1's medication which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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ADM will submit a POC by due date to provide training to staff to ensure Centrally Stored Medication Form is up to date and filled correctly.
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:Jackie Jin
LICENSING EVALUATOR NAME:Kenneth Madrigal
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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