435202991-12-15-2025-26-AS-MTAN-DPDQTR-20251215112734

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202991
Report Date: 12/15/2025
Date Signed: 12/15/2025 11:27:44 AM

Document Has Been Signed on 12/15/2025 11:27 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:	A'S HOME CARE FOR ELDERLY		FACILITY NUMBER:	435202991
ADMINISTRATOR/ DIRECTOR:	GUILLERMO, JOSEPHINE		FACILITY TYPE:	740
ADDRESS:	6797 MOSELLE DR		TELEPHONE:	(408) 802-2689
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95119
CAPACITY: 6		CENSUS: 2	DATE:	12/15/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Applicant Josephine Guillermo		TIME VISIT/ INSPECTION COMPLETED:	11:30 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	Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct the facility's pre-licensing visit. LPA met with Applicant Josephine Guillermo. There are 2 residents present on site. This facility address is currently licensed (43520259) and is under a change of ownership (CHOW). During visit, LPA toured the inside and outside of the facility to include the kitchen, dining, living room, garage,and 5 resident rooms, 1 staff room. The facility had a Ring doorbell at the front door. No bodies of water were observed. Facility temperature maintained at 71 F. Based on the facility fire clearance, the facility is approved for 5 NON-AMBULATORY of which 1 may be BEDRIDDEN in Bedroom #2, which has an exit to the exterior. All exit and passage ways were free and clear of obstruction. LPA observed a nonperishable food supply of 7 days and a perishable food supply of 2 days. LPA observed sharp supplies in a locked drawer in the kitchen. Fire extinguisher was inspected on 5/1/2025. The facility fire protection system was inspected on 9/17/2025 by the local fire department. LPA observed medications locked in a kitchen cabinet inaccessible to residents in care. LPA toured 5 Resident bedrooms. Bedrooms 1, 2 and 3 have an exit doorway leading out to the perimeter. Page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

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: A'S HOME CARE FOR ELDERLY	FACILITY NUMBER: 435202991
	VISIT DATE: 12/15/2025

NARRATIVE

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LPA observed 1 Camera in the living room area. Applicant states the camera does not work. No cameras were observed in resident rooms. The following posters observed to include the emergency telephone numbers, personal rights, and facility sketch in the living room area.

LPA toured the garage area and observed a washer, and a dryer. LPA also observed toxins secured in locked cabinets. LPA observed the facility garage as locked and inaccessible to residents. The facility garage is OFF LIMITS and is not to be used as a habitual (living) space for residents or staff. Applicant stated understanding and that no staff or residents will use the garage as a habitual space.

LPA toured 3 resident bathrooms and observed the bathrooms to have functioning lights, covered trash bins, and hand soap. LPA measured water temperature with a range from 110.8 F to 119.8 F.

Monitoring devices are in place, playing an auditory sound when a facility exit door is opened, which can be heard throughout the facility.

Areas of corrections were discussed during today's visit with the applicant, which included the facility physical plant.

LPA observed the facility to have damaged flooring in the kitchen near the sink, a damaged window sill in Bedroom #4, and damaged closet door tracks and blinds in Bedrooms #4 and 5. Bedroom #5 also had a damaged window screen. In addition, LPA observed 4 loose wooden handrails outside the kitchen sliding door and outside Bedroom #1, and the kitchen screen door to have a large hole near the screen handle. The current licensee needs to address that damaged areas and ensure there are no damaged, loose or broken areas prior to issuing license to new owner.

Pre-Licensing is incomplete with corrections/deficiencies to be resolved by 12/22/2025. A follow up Pre-licensure LIC809 will be generated upon resolution of corrections/deficiencies.

No deficiencies were cited per California Code of Regulations, Title 22. An exit interview was conducted with Applicant Josephine Guillermo and a copy of this report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC809 (FAS) - (06/04)

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