<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202891
Report Date: 10/04/2024
Date Signed: 10/04/2024 02:38:00 PM

Document Has Been Signed on 10/04/2024 02:38 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:RGK HOME CAREFACILITY NUMBER:
435202891
ADMINISTRATOR/
DIRECTOR:		LAZARO, MARY GRACE V.FACILITY TYPE:
740
ADDRESS:274 CLEARPARK CIRCLETELEPHONE:
(408) 420-7262
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 6DATE:
10/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Administator Mary Grace LazaroTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Manuel Monter and Marcella Tarin conducted an unannounced case management to amend a complaint (26-AS-20240523112616), LIC9099-D issued on September 17, 2024. LPA met with Administrator Mary Grace Lazaro and explained the purpose of the visit.

The report issued on September 17, 2024 is being amended to issue a civil penalty for absence of supervision, which resulted in resident R1, eloping from the facility on May 21, 2024. The LIC9099-D deficiency will be amended due an erroneous error. The code section cited in the deficiency (87464 Basic Services(f)(1)) was incorrect, and the correct code section will be cited.

No deficiencies were cited during todays visit. This Report was reviewed with Administrator Mary Grace Lazaro. A signed copy was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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 1