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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202891
Report Date:
03/13/2025
Date Signed:
03/13/2025 05:25:13 PM
Document Has Been Signed on
03/13/2025 05:25 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 CARE
FACILITY NUMBER:
435202891
ADMINISTRATOR/
DIRECTOR:
LAZARO, MARY GRACE V.
FACILITY TYPE:
740
ADDRESS:
274 CLEARPARK CIRCLE
TELEPHONE:
(408) 420-7262
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95136
CAPACITY:
6
CENSUS:
5
DATE:
03/13/2025
TYPE OF VISIT:
Case Management - Legal/Non-compliance
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:
Annie Inciso
TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Legal/Non-compliance inspection and met with House Manager (HM) Annie Inciso.
The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) office after a Non-Compliance Conference held on 12/03/2024. The case management of inspections will be conducted every 3 months for 2 years.
LPA reviewed and discussed the plan of correction for the deficiencies and the plan of operation the facility submitted for the NCC meeting with the HM.
LPA reviewed the appraisal needs and service plan of residents.
LPA toured the facility with HM. LPA checked the 3 door alarms of the facility and 2 moving detectors alarms outside the building.
LPA reviewed the facility staff training log. LPA reviewed the 15 minutes resident checking log.
Exit interview was conducted with HM. The report was provided to HM for signature. A copy of the report was provided to HM.
SUPERVISORS NAME
:
Romeo Manzano
LICENSING EVALUATOR NAME
:
Chihhsien Chang
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/13/2025
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/13/2025
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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