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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202894
Report Date: 03/25/2026
Date Signed: 03/26/2026 07:33:59 AM

Document Has Been Signed on 03/26/2026 07:33 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 FEELS RESIDENTIAL CARE 3FACILITY NUMBER:
435202894
ADMINISTRATOR/
DIRECTOR:		GARCIA, RITAFACILITY TYPE:
740
ADDRESS:770 PRONTO DRTELEPHONE:
(408) 440-2916
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
03/25/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Philipp Perez - Designated administratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 03/25/2026, Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to address a complaint that was filed with the Department on 03/17/2026. This case management is not part of the complaint. This case management - deficiencies is based on LPAs observation at the time of the visit. During the visit LPA was accompanied by the designated administrator Philipp Perez. Licensee/Administrator (LIC/ADM) David Devries is not available at the time of the visit due to prior commitment.

The facility is licensed to serve adults age 60 and over with a capacity of 6, of which may be ambulatory and 6 may be non-ambulatory and a hospice waiver for 6. LPA conducted inspection inside and outside, including but not limited to the kitchen, dining area, 4 out 4 resident bedroom, 2 out 2 bathrooms, 1 staff room, exterior perimeters, and interior area of the facility.

During inspection, LPA observed no tripping hazard on the hallways and emergency exits. LPA observed Arm and Hammer laundry detergent and Downy liquid cloth softener not locked in the laundry area that is located in the pass through from the inside towards the garage area and accessible to residents in care. S1 stated one of the resident likes to do their laundry at night that's why they leave the detergents inside the cabinet and not locked. LPA observed a steak knife that was not locked and is accessible to residents in care in the left corner drawer of the counter located in the kitchen. LPA observed the kitchen vent was covered with accumulated oil residue.

page 1 of 2 see LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2026
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 FEELS RESIDENTIAL CARE 3
FACILITY NUMBER: 435202894
VISIT DATE: 03/25/2026
NARRATIVE
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LPA observed the screen of the sliding door was frayed and has a hole that can fit a hand (Room #3). The facility has a side ramp and a ramp at the back to accommodate non-ambulatory individuals. The ramp's railing is not sturdy when touched lightly. LPA observed a green colored lighter on top of a table next to an frayed upholstered arm chair located at the back of the property by the exit sliding door. LPA observed frayed upholstered recliner next to the back ramp railing a chair that is broken next to the fence, and a power lifting press bench with frayed leatherette cover, cobwebs and rust.

LPA inspected 5 bedrooms, 4 are for residents and 1 is for staff. 2 out of the 4 are shared and 2 are not shared. 1 out of the four has a bathroom and 1 shared bathroom in the hallway. The bathroom are equipped with grab bars and anti-slip mats. A sign that residents are not allowed in the garage is visible and door is kept closed and locked. LPA observed a carbon monoxide alarm system and a broken smoke alarm system at the entry hallway. The facility has 2 days of perishable food and 7 days of non-perishable foods.

LPA observed a fire extinguisher that was last inspected on 08/12/2025 located near the kitchen, a dried pumpkin by the fireplace was also observed. LPA observed 3 out of 6 residents having breakfast on the dining table. LPA covered clear plastic container with each person's name written on a sticker. 2 out of 6 was asleep and 1 out of 6 was outside. When asked what is inside the clear container. The 3 residents and 2 out of 3 staff stated that the container is used for resident's medications. Staff 1 (S1) stated that the medications for breakfast are pre-poured or pre-prepared in the evening and given during breakfast.

LPA reviewed 2 out of 2 staff record. 2 out of 2 staff have cleared criminal background and fingerprint record and are associated with the facility. 1 out 2 staff have a 1st Aid/CPR certification that will expire on June 08,2026. 1 out of 2 staff was recently hired and is currently in training. LPA reviewed 4 out of 6 resident record, the records were complete and up to date.

Deficiencies are cited during today's case management - deficiencies based on California Code of Regulations (CCR) Title 22 See LIC 809D. An exit interview was conducted with designated administrator (DADM) Philipp Perez. A copy of the report and appeal's rights were provided.

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end of report
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/26/2026 07:34 AM - It Cannot Be Edited


Created By: Maria Partoza On 03/25/2026 at 03:24 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: FAMILY FEELS RESIDENTIAL CARE 3
FACILITY NUMBER: 435202894

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/26/2026
Section Cited
CCR
87309(a)

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87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure...cleaning solutions ...knives.. are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
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DADM, stated that he/she will ensure that LIC/ADM is aware of the deficiency and will have LIC/ADM submit a written plan of correction to address the deficiency regarding storage of laundry detergents and sharp objects by the POC due date of 03/26/2026.
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Based on LPA observation during inspection, the LIC/ADM did not ensure that the Arm&Hammer laundry detergent, Downy Softener and steak knife are in locked storage and are not left unattended when not in use.
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Type A
03/26/2026
Section Cited
CCR87303(a)

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87303 Maintenance & Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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properly installed,upholstered furnitures, and excercise equipment that were placed outdoors are in good and usable condition. for the safety and well-being of residents, employees and visitors.
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Based on LPAs observation during facility inspection, LIC/ADM did not ensure that the facility is kept maintained by not addressing the following: back ramp rail sturdiness, frayed sliding door screen in room #3, kitchen vent is kept free from accumulated residue, smoke alarm is
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DADM, stated that he/she will ensure that LIC/ADM is aware of the deficiency and will have LIC/ADM submit a written plan of correction to address the deficiency regarding maintenance of the facility by the POC due date of 03/26/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/26/2026 07:34 AM - It Cannot Be Edited


Created By: Maria Partoza On 03/25/2026 at 04:16 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: FAMILY FEELS RESIDENTIAL CARE 3
FACILITY NUMBER: 435202894

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/26/2026
Section Cited
CCR
87465(h)(5)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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container and not transferred between container.
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This requirement is not met as evidenced by:
Based on LPAs observation and staff statement, resident's morning medications are pre-prepared the night before and given to residents in the morning during breakfast. The LIC/ADM did not ensure that resident's medication are stored in its original received
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DADM, stated that he/she will ensure that LIC/ADM is aware of the deficiency and will have LIC/ADM submit a written plan of correction to address the deficiency regarding transfering of medication between containers by the POC due date of 03/26/2026.

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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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
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