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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202940
Report Date: 06/10/2024
Date Signed: 06/10/2024 10:45:54 AM

Document Has Been Signed on 06/10/2024 10:45 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:COMPASSIONATE SENIOR CAREFACILITY NUMBER:
435202940
ADMINISTRATOR/
DIRECTOR:		PANGALIMAN, LEILANIEFACILITY TYPE:
740
ADDRESS:2604 CHERRY AVETELEPHONE:
(209) 814-8004
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 0DATE:
06/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Administrator Leilanie PangalimanTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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On June 10, 2024, Licensing Program Analyst (LPA) Manuel Monter, conducted an announced pre-licensing inspection and met with Administrator(ADM) Leilanie Pangaliman.

The facility is a Residential Care Facility for the Elderly (RCFE). The facility fire clearance is approved for 5 non-ambulatory clients and 1 bedridden. At the time of inspection there are no clients observed.

LPA and ADM toured the facility inside and outside. which included the Living room, kitchen, dining room, 2 restrooms and 5 residents bedrooms. The staff room in the facility was also observed. The front yard and backyard were inspected. There was no obstruction to block the walkways. While touring the backyard, LPA observed a storage shed, adjacent to bedroom #5, being used as storage.

The facility has 4 designated exit routes per LIC 610D (emergency and disaster plan), front door, Bedroom #2, Bedroom #3, Bedroom #4. The exit is free from obstruction. The facility has carbon monoxide and smoke alarm detectors that are strategically placed throughout the building. The facility fire extinguishers are placed strategically in the Kitchen and Living room. The fire extinguishers were serviced on June 10, 2024.

The laundry area is located in the garage. The laundry detergents, cleaning supplies and other toxic are locked and can only be accessed by staff.

5 Out of 5 resident bedrooms have adequate lighting, bed frames with mattress, linens, lamps, night stands, drawer dresser storage and closet space that is sufficient to store clients’ personal belongings.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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 2
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: COMPASSIONATE SENIOR CARE
FACILITY NUMBER: 435202940
VISIT DATE: 06/10/2024
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2 Out of 2 bathrooms hot water temperature measured to range from 107 to 109 degrees Fahrenheit. Room temperature is at 70 degree F. The facility has a centralized air-conditioning system.

Medication cabinet observed to be locked. First Aid kit was observed inside medication closet, which contained first aid supplies, with manual, tweezers and scissor. Facility kitchen equipment is functioning properly, LPA observed locked drawer for sharps. LPA reviewed emergency disaster plan and confirmed its completeness. LPA observed storage closed for containment of cleaning chemicals. Facility bulletin board contain all necessary documents. No issues noted during this Pre-Licensing Inspection.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Component III orientation was conducted with ADM Leilanie Pangaliman. This report was reviewed with Administrator (ADM) Leilanie Pangaliman and a copy of the report was provided.

END OF REPORT

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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