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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202912
Report Date: 08/14/2024
Date Signed: 08/21/2024 09:04:10 AM

Document Has Been Signed on 08/21/2024 09:04 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MARY'S HOUSE #2FACILITY NUMBER:
435202912
ADMINISTRATOR/
DIRECTOR:		MENDOZA, ROSANAFACILITY TYPE:
740
ADDRESS:324 BURNING TREE DRTELEPHONE:
(408) 439-1703
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6CENSUS: 4DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Armando GubaTIME VISIT/
INSPECTION COMPLETED:
01:45 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 Analysts (LPAs) David Marrufo and Santino Fortes conducted an unannounced Required 1 Year visit and met with Armando Guba, Administrator.

During visit, LPAs toured the facility inside and out. LPAs toured the facility kitchen area. LPAs observed a prescription inhalation mediation left unsecured on the kitchen island surface. Staff placed the unsecured medication in the locked medication storage cabinet during visit. LPAs observed an uncovered container containing a cut lemon and another food item inside the refrigerator. Staff removed the uncovered container from the refrigerator during visit. LPAs observed the locked cabinet where sharp objects are stored. LPAs observed the locked storage cabinet used to store medications and records. LPAs observed the first aid kit and found it to be complete.

LPAs toured 2 out of 2 resident bathrooms and observed each bathroom had working lights and available soap and paper towels. The showers in each bathrooms had grab bars and anti-slip mats. The water temperatures in the bathroom sinks measures at 118 F and 115 F.

LPAs toured 5 out of 5 resident bedrooms and found each bedroom to have working lights and available bedding and clothing storage areas. LPAs tested the smoke detectors and carbon monoxide detectors in the hallways and each resident rooms and found them to function properly when tested. LPAs toured the outside area and found the exits were clear of obstructions. LPAs reviewed the Centrally Stored Medication and Destruction Records (CSMDRs) for 4 out of 4 residents. Resident R1 had 2 medications missing from the CSMDR. Resident R2 had 2 medications missing from the CSMDR. R3 had 5 medications missing from the CSMDR and 2 medications did not have a prescription label. R4 had two medications missing from the CSMDR. LPAs reviewed 4 out of 4 staff records. R1-R4 were missing Safeguard for Property and Valuables Forms and R3-R4 were missing Pre-Appraisal Forms. LPAs reviewed 1 out of 1 staff records and found it to be complete. See LIC809-C for more information. Page 1 of 2.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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 5
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: MARY'S HOUSE #2
FACILITY NUMBER: 435202912
VISIT DATE: 08/14/2024
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
26
27
28
29
30
31
32
During visit, Administrator Armando Guba stated that volunteer V1 did not have a health statement or health screening form on record.

Advisory Notes were issued. See LIC9102 pages for more information.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information.

This report was reviewed with Administrator Armando Guba and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/21/2024 09:04 AM - It Cannot Be Edited


Created By: David Marrufo On 08/14/2024 at 12:28 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: MARY'S HOUSE #2
FACILITY NUMBER: 435202912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2024
Section Cited

1
2
3
4
5
6
7
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one
8
9
10
11
12
13
14
year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication.

This requirement was not met as evidenced by: Licensee did not ensure that 4 out of 4 reviewed resident Centrally Stored Medication and Destruction Records did not have centrally stored medications that were not recorded. R1 had 2 unrecorded medications, R2 had 2 unrecorded medications, R3 had 5 unrecorded medications, and R4 had 2 unrecorded medications, which poses a potential health risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/21/2024 09:04 AM - It Cannot Be Edited


Created By: David Marrufo On 08/14/2024 at 12:30 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: MARY'S HOUSE #2
FACILITY NUMBER: 435202912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2024
Section Cited

1
2
3
4
5
6
7
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Licensee did not ensure that resident R3 did not have two medications that did not have a prescription label, which poses a potential safety risk to residents in care.
8
9
10
11
12
13
14
Type B
08/21/2024
Section Cited

1
2
3
4
5
6
7
(b) Personnel records shall be maintained for all volunteers and shall contain the following: (1) A health statement as specified in Section 87411(f). (2) Health screening documents as specified in Section 87411(f). This requirement was not met as evidenced by: Licensee did not
8
9
10
11
12
13
14
ensure that Volunteer V1 had a health statement and health screening on record, which poses a potential health risk to residents in care.
8
9
10
11
12
13
14
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:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/21/2024 09:04 AM - It Cannot Be Edited


Created By: David Marrufo On 08/14/2024 at 12:35 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: MARY'S HOUSE #2
FACILITY NUMBER: 435202912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2024
Section Cited

1
2
3
4
5
6
7
(b) Each resident’s record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement was not
8
9
10
11
12
13
14
met as evidenced by: Licensee did not ensure that residents R1-R4 had Safeguard for Property and Valuables Forms in their resident records, which poses a potential personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
08/21/2024
Section Cited

1
2
3
4
5
6
7
(b) Each resident’s record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal; This requirement was not met as evidenced by: Licensee
8
9
10
11
12
13
14
did not ensure that residents R4 and R5 had Pre-Admission Appraisal forms in their resident records, which poses an potential safety risk to residents in care.
8
9
10
11
12
13
14
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:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5