435202918-10-2-2025-26-AS-DMAO-DM3SZ9-20251002141845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202918
Report Date: 10/02/2025
Date Signed: 10/02/2025 02:18:54 PM

Document Has Been Signed on 10/02/2025 02:18 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:	UMBRELLA RESIDENTIAL CARE		FACILITY NUMBER:	435202918
ADMINISTRATOR/ DIRECTOR:	VALLARTA, ANABELEN D.		FACILITY TYPE:	740
ADDRESS:	4623 MANGRUM DRIVE		TELEPHONE:	(510) 709-7078
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95054
CAPACITY: 6		CENSUS: 5	DATE:	10/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Anabelen Vallarta		TIME VISIT/ INSPECTION COMPLETED:	02:30 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 (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Anabelen Vallarta. During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be locked drawers and cabinets for sharp objects and cleaning supplies. LPA observed the first aid kit was complete. LPA toured five out of five bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA toured 3 out of 3 bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathrooms ranged from 110 F to 112 F. LPA tested two out of two carbon monoxide detectors and the smoke detectors in the hallways and resident bedrooms. All carbon monoxide and smoke detectors functioned properly when tested. LPA toured the outside area and found the exits were clear of obstruction. LPA reviewed the Centrally Stored Medication and Destruction Records for residents R1-R5. Resident R1 had five medications missing. R2 had three medications missing. R3-R5 did not have any medications missing. See LIC809-C page for more information. Page 1 of 2.

NAME OF LICENSING PROGRAM MANAGER: Maria Partoza
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

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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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: UMBRELLA RESIDENTIAL CARE	FACILITY NUMBER: 435202918
	VISIT DATE: 10/02/2025

NARRATIVE

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LPA reviewed the resident records of R1-R5 and found them to be complete. LPA reviewed two staff records and found them to be complete.

The emergency disaster drill log indicates the last drill occurred on 09/03/2025.

LPA Marrufo requests that updated copies of the following records be submitted to the department within seven calendar days:

LIC500 Personnel Report
LIC308 Designation of Administrative Responsibility
Liability Insurance
LIC610E Emergency Disaster Plan

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information.

This report was reviewed with Administrator Anabelen Vallarta and a copy of this report and appeal rights were provided.

Page 2 of 2.

END REPORT

NAME OF LICENSING PROGRAM MANAGER: Maria Partoza
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/02/2025 02:18 PM - It Cannot Be Edited

Created By: David Marrufo On 10/02/2025 at 02:03 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: UMBRELLA RESIDENTIAL CARE	FACILITY NUMBER: 435202918
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)(A)-(F)

87465 Incidental Medical and Dental Care (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: (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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of 5 out of 5 Centrally Stored Medication and Destruction Records(CSMDR), the Licensee did not ensure that 2 out of 5 CSMDRs did not have missing medications, which poses a potential health risk to residents in care.
	POC Due Date: 10/09/2025
	Plan of Correction
1 2 3 4	Licensee agrees to conduct in-service training with staff on ensuring that there is a record for all centrally stored medications and maintain compliance with regulation 87465(h)(6)(A)-(F) and submit staff training records to the department by Plan of Correction Due date of 10/09/2025. Training records should include names of staff trained, training dates, training topic(s), and names and qualifications of trainer.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Maria Partoza
NAME OF LICENSING PROGRAM MANAGER:

	David Marrufo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

LIC809 (FAS) - (06/04)

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