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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202912
Report Date: 08/19/2025
Date Signed: 08/19/2025 07:06:54 PM

Document Has Been Signed on 08/19/2025 07:06 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: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: 3DATE:
08/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Armando GubaTIME VISIT/
INSPECTION COMPLETED:
07:10 PM
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's requires - 1 year annual inspection. LPA met with Administrator, Armando Guba.
During visit, LPA toured the facility to include the resident bedrooms, bathrooms, living room, kitchen, garage and backyard. All fire exit routes were free and clear of obstruction.
There were 2 staff present to 3 residents. 2 out of 3 residents are under hospice care.

The 2 staff present are fingerprint cleared, but 1 out of the 2 staff are not associated to the facility. Administrator admitted that 1 staff member was not associated to the facility as the staff was added to the schedule last minute. The Administrator immediately submitted the LIC9182 form to the Department to associate the staff to the facility roster. A technical violation was provided per Section 87355(e)(3) reminding the facility to ensure all staff working are requested a transfer of a criminal record clearance prior to work.

Facility temperature maintained at 78 degrees F. Fire extinguisher last serviced on 08/01/2025. Emergency lighting observed in the hallway. Smoke detector and carbon monoxide detector was tested and observed operable. Bathroom hot water temperature maintained at 117.8 degrees F. The bathroom shower observed with non-slip mats and grab bars. Facility has at least 2 days worth of perishables and 7 days worth of non-perishables foods. Refrigerator temperature maintained at 35.6 degrees F. Freezer temperature maintained at -4 degrees F. Page 1 of 4.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2025
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 13
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: MARY'S HOUSE #2
FACILITY NUMBER: 435202912
VISIT DATE: 08/19/2025
NARRATIVE
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Sharp objects, chemicals, disinfectants, and medications were not locked during the visit but the staff was present in the kitchen area. LPA advised the staff to ensure these items are locked when staff leave the area. Staff immediately locked the cabinets and drawers during visit.

Resident bedrooms equipped with proper furniture, lighting, night stand, and dresser. 1 resident who is under hospice care observed using oxygen. Oxygen in use sign observed posted on the door.

1 resident (R1) bedroom observed with full bed rails. The resident is not under hospice care. Based on review of the facility's file, the facility did not submit any exception regarding the use of full bed rails. LPA reviewed the resident's records and did not observe a physician's order for the full bed rails. LPA observed a letter from the resident's responsible party supporting the use of full bed rails as the resident is fall risk. Administrator was advised of Title 22 regulation Section 87608. A type A deficiency was cited today per Section 87608(a)(5)(B) wherein 1 resident who is not under hospice care is utilizing full bed rails without prior approval from the Department.

LPA observed the garage is being used as a sleeping quarters for 2 staff members (S1 - S2). Photographs of the garage were taken. Based on the facility sketch and fire clearance, the garage is not approved to be used as a living quarter for staff. Staff stated there was a total of 3 live-in staff members. The other staff member (S3) is using the living room couch as a sleeping area. A type A deficiency was cited today per Section 87307(a) wherein the live-in staff are residing in the garage and living room which is not related to the facility's functions per the facility sketch.

LPA reviewed 3 resident files. 3 out of 3 resident files were not complete and up to date. 3 resident files contained an admission agreement, consent form, personal rights, and identification and emergency contact information. However, 1 resident (R1) did not have a medical assessment on file prior to admission. Resident (R2) has dementia and the last medical assessment was last completed on 09/08/2023. Resident (R3) who was placed under hospice care on 12/27/2024, medical assessment was last completed on 08/08/2022. A type B deficiency was cited today per Section 87463(h) wherein 1 resident did not have a medical assessment on file and 2 resident's medical assessments were not updated within the last 12 months. Page 2 of 4.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 13
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: 08/19/2025
NARRATIVE
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2 out of 3 residents did not have a reappraisal completed. 1 out of 3 residents had a reappraisal, however the reappraisal was not signed by the resident and/or resident's responsible party. A type B deficiency was cited today per Section 87463(a) wherein 2 residents reappraisals was not updated as necessary and 1 resident's reappraisal was not signed by the resident/resident responsible party.

LPA reviewed 3 residents centrally stored medications and centrally stored medication records. LPA observed that 3 residents centrally stored medication records were not complete as there was 16 medications from R1 - R3 that were not written in the centrally stored medication record (CSMR). A type B deficiency was cited today per Section 87465(h)(6) wherein there was 16 medications from R1 - R3 that was not maintained in the resident's CMSR.

LPA observed that that residents require PRN medications at the facility. Based on the facility's record review and confirmed by the Administrator, the facility does not have a PRN log in the resident's records to include the date/time PRN was taken, dosage, and resident's response to the PRN. A technical violation was provided per Section 87465(c)(3).

LPA reviewed 4 staff members files. 4 out of 4 staff members has a fingerprint clearance. 4 out of 4 staff members does not have a 1st aid certification. A type B deficiency was cited today per HSC 1569.618(c)(3) wherein 4 staff members does not have a 1st aid certification.

3 out of 4 staff members does not have a TB result. A type A deficiency was cited today per Section 87411(f) wherein 3 staff members does not have a complete health screening to include a TB result on file prior to working in the facility.

4 out of 4 staff members does not have any initial or annual training provided per Title 22 regulations. A type B deficiency was cited today per Section 87411(c) wherein 4 staff members who assist residents with activities of daily living has not received initial and annual training. Page 3 of 4.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
Page: 4 of 13
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: 08/19/2025
NARRATIVE
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The facility has not completed any emergency disaster drills. A type B deficiency was cited today per HSC 1569.695(c) wherein the facility has not conducted any emergency drills.

The following documents were requested by 08/26/2025 to be sent to the licensing general email to include: LIC500, emergency disaster plan, LIC308, and Administrator certificates.

Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809D. Advisory note provided. This report was reviewed with Administrator, Armando Guba and a copy of the report and appeal rights were provided.

Page 4 of 4.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 08/19/2025 07:06 PM - It Cannot Be Edited


Created By: Christine Kabariti On 08/19/2025 at 06:02 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: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, … Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 1 resident who is not under hospice care is utilizing full bed rails which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
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Administrator states to reach out to the resident's doctor to see if the doctor will approve of the full bed rails. Administrator states in the meantime, he will remove one of the rails to create a half rail on the resident's bed and train staff on the resident's care plan on increased monitoring to prevent falls. Administrator will submit a photo of the bed and training record to LPA Kabariti via email by POC due date of 08/20/2025.
Type A
Section Cited
CCR
87307(a)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above wherein 2 staff members are residing in the garage and 1 staff is residing the living room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
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Administrator states 1 of the vacant bedrooms will be used as a staff living quarters for the live-in staff. Administrator will submit an updated facility sketch to show which room will be used a staff bedroom to LPA Kabariti via email by POC due date on 08/20/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
Page: 7 of 13
Document Has Been Signed on 08/19/2025 07:06 PM - It Cannot Be Edited


Created By: Christine Kabariti On 08/19/2025 at 06:17 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: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 1 resident does not have a medical assessment prior to admission and 2 residents medical assessment has not been updated annually which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Administrator states he will update all residents physician's reports. Administrator states he will submit the updated physician's report for 3 residents to the Department's general email by POC due date of 08/26/2025.
Type B
Section Cited
CCR
87463(a)
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 2 resident's did not have a reappraisal and 1 resident's reappraisal was not signed by the resident/responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Administrator states he will update the 3 residents reappraisals. Administrator states he will submit the 3 resident's updated and signed reappraisal to the Department's general email by POC due date of 08/26/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
Page: 8 of 13
Document Has Been Signed on 08/19/2025 07:06 PM - It Cannot Be Edited


Created By: Christine Kabariti On 08/19/2025 at 06:26 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: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
(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 year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above wherein there was a total of 16 residents medications that was not written in the centrally stored medication record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Administrator states he will provide training with staff on medications. Administrator will submit the training record to the Department's general email by POC due date of 08/26/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
Page: 9 of 13
Document Has Been Signed on 08/19/2025 07:06 PM - It Cannot Be Edited


Created By: Christine Kabariti On 08/19/2025 at 06:38 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: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 4 staff members do not have a CPR and first aid training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Administrator states to submit the 4 staff members 1st aid certification to the Department's email box by POC due date 08/26/2025.
Type B
Section Cited
CCR
87411(c)
(b) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in wherein 4 staff members are not provided initial and annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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2
3
4
Administrator states he will enroll all the staff in training. Administrator will submit a scheduled plan for the 4 staff to complete training to the general email box by POC due date of 08/26/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
Page: 11 of 13
Document Has Been Signed on 08/19/2025 07:06 PM - It Cannot Be Edited


Created By: Christine Kabariti On 08/19/2025 at 06:44 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: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. …

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 3 staff members does not have a TB result which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
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2
3
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Administrator states the 3 staff members will complete the TB test by 08/20/2025. Administrator will submit proof that the TB test was completed by POC due date of 08/20/2025.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
Page: 12 of 13
Document Has Been Signed on 08/19/2025 07:06 PM - It Cannot Be Edited


Created By: Christine Kabariti On 08/19/2025 at 06:47 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: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1569.695(c)
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in wherein the facility is not completing emergency drills quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Administrator will conduct an emergency drill with the staff, ASAP. Administrator will create a schedule for the emergency drills for the staff going foward. Administrator will submit proof that the emergency drill was completed and the schedule for going forward to the Department general email by POC due date of 08/26/2025.
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.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


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