435202969-10-20-2025-26-AS-MMOR-DMMNFJ-20251020102537

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202969
Report Date: 10/20/2025
Date Signed: 10/20/2025 10:25:48 AM

Document Has Been Signed on 10/20/2025 10:25 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:	MINA'S ELDERLY CARE HOME 1		FACILITY NUMBER:	435202969
ADMINISTRATOR/ DIRECTOR:	ABBASVAND, MINA		FACILITY TYPE:	740
ADDRESS:	112 GARDEN HILL DRIVE		TELEPHONE:	(408) 884-8858
CITY:	LOS GATOS	STATE: CA	ZIP CODE:	95032
CAPACITY: 6		CENSUS: 6	DATE:	10/20/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Administrator Mina Abbasvand		TIME VISIT/ INSPECTION COMPLETED:	10:30 AM

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	On October 20, 2025, Licensing Program Analyst (LPA) Manuel Monter, conducted an announced pre-licensing inspection and met with Administrator Mina Abbasvand. This pre-licensing visit is a Change of Ownership, from the previous Facility 435202672 MINAS ELDERLY CARE HOME 1, to 435202969 MINA'S ELDERLY CARE HOME 1. The facility is a Residential Care Facility for the Elderly (RCFE). The facility fire clearance is approved for 5 nonambulatory & 1 bedridden. At the time of inspection there are 6 clients observed. LPA and ADM toured the facility inside and outside, which included the Living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. The front yard and backyard were inspected. There was no obstruction to block the walkways. LPA toured in the facility garage, which is being used as a storage space. LPA toured the 2nd floor of the facility, which contains 2 staff bedrooms & 1 bathroom. ADM stated the second floor of the facility is for staff use only. The facility has 4 designated exit routes per LIC 610D (emergency and disaster plan). The exits are 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. The fire extinguishers were serviced on April 17, 2025. Page 1 Out of 2.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025

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: MINA'S ELDERLY CARE HOME 1	FACILITY NUMBER: 435202969
	VISIT DATE: 10/20/2025

NARRATIVE

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The laundry area is located in the adjacent to bedroom 6 and the kitchen. The laundry detergents, cleaning supplies and other toxic are locked and can only be accessed by staff. Facility bulletin board contain all necessary documents. LPA observed 7 days of perishable and non perishable food supplies.

6 Out of 6 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.

3 Out of 3 bathrooms hot water temperature measured at 112 degrees Fahrenheit. Room temperature is at 71 degree F. The facility has a centralized air-conditioning system.

Medication closest observed to be locked. First Aid kit was observed, which contained first aid supplies, with manual, tweezers and scissor. Facility kitchen equipment is functioning properly, LPA observed locked closet for sharps. LPA reviewed emergency disaster plan and confirmed its completeness. LPA observed cleaning products and chemicals locked an inaccessible to residents in care. 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 Administrator Mina Abbasvand. This report was reviewed with Administrator Mina Abbasvand and a copy of the report was provided.

END OF REPORT

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025

LIC809 (FAS) - (06/04)

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