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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294155
Report Date: 07/22/2025
Date Signed: 07/22/2025 01:52:44 PM

Document Has Been Signed on 07/22/2025 01:52 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:ST. ANNE'S HOME FOR ELDERLYFACILITY NUMBER:
435294155
ADMINISTRATOR/
DIRECTOR:		BANAAG M., MANALO MAYLENEFACILITY TYPE:
740
ADDRESS:790 LAKEBIRD DRIVETELEPHONE:
(408) 744-1752
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY: 6CENSUS: 5DATE:
07/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Melinda ManaloTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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On July 22, 2025, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Administrator, Maylene Manalo, and disclosed the purpose of the inspection. The Administrator informed the LPA that the facility had five (5) residents in care and (2) staff members present at the time. The Licensee, Melinda Manalo joined shortly after.

At 9:15 AM, the LPA initiated a walk-through of the facility, accompanied by the Administrator.

LPA inspected the kitchen and found it clean, with no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet containing knives and sharp objects. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted.

LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. One (1) resident was observed eating breakfast.

LPA inspected the living room and observed it clean, with all furniture in good repair. There were chairs, tables, and a television in the living room.

There were five (5) bedrooms and four (4) bathrooms designated for residents' use. All five (5) resident rooms were single occupancy. LPA inspected all resident rooms and found them clean, well-lit, and equipped with the required furniture.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2025
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: ST. ANNE'S HOME FOR ELDERLY
FACILITY NUMBER: 435294155
VISIT DATE: 07/22/2025
NARRATIVE
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At 9:38, LPA observed that non-ambulatory residents R4 and R5 in room #5 and room #2 respectively. Room #2 and #5 didn’t have an approved fire clearance for non-ambulatory residents.

LPA inspected two (2) bathrooms and found them sanitary, and in good working conditions. The bathrooms contained soap, grab bars, a trash can, a shower chair, and non-slip flooring/mats. The hot water temperature at the sink faucet in both bathrooms was measured between that range of 119.4°F to 119.6°F.

LPA inspected the fire extinguisher mounted on the wall in the hallway next to dining area and found it fully charged, with the last service tag dated 01/16/2025. The smoke and carbon monoxide detector located in the living room was tested and it was found to be functional. Additional smoke detectors were observed in all bedrooms and common areas of the facility during the visit.

LPA inspected the (2) storage closets in the hallway and observed them contained clean linens, blankets, and towels for residents’ use.

LPA inspected the laundry/utility area and found it clean. A washer, a dryer, and a refrigerator, a freezer containing additional food supplies, and a pantry cabinet with non-perishable food items were observed.

LPA toured the front porch and backyard areas, and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The porch and backyard had a table, chairs, and shaded areas for resident use. Detergents, disinfectants, and cleaning supplies were observed in a locked cabinet in the backyard. No bodies of water were noted. LPA inspected (1) storage shed in the backyard and noted incontinence supplies, paper tissues, and other supplies stored.

At 10:30 AM, LPA reviewed three (3) staff personnel records and five (5) resident records. The LPA observed that 3 of 5 residents were not seen by a physician in the last 12 months and 1 of 5 residents did not have the pre-admission appraisal. LPA observed that 3 of 3 staff members had LIC 508 Criminal Record Statements, LIC 503 Health Screening, and confirmed that 3 of 3 staff members were associated with the facility.

At 11:50 AM, LPA observed a locked centrally stored medication cabinet next to the dining area. Medications were organized in separate bins for each resident. Centrally Stored Medication Records were reviewed and LPA observed 1 of 5 residents (R1) medication that was administered to R1 was not entered/logged in the Centrally Stored Medication Records.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC809 (FAS) - (06/04)
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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: ST. ANNE'S HOME FOR ELDERLY
FACILITY NUMBER: 435294155
VISIT DATE: 07/22/2025
NARRATIVE
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LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were not conducted quarterly, with the most recent drill completed on 06/20/2023.

The following updated forms are requested to be submitted to CCLD by 07/29/2025:

  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • Certificate of Liability Insurance
  • Administrator Certificate(s)

The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with the Licensee, Melinda Manalo, whose signature on this form confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2025 01:52 PM - It Cannot Be Edited


Created By: Kiran Jain On 07/22/2025 at 01:03 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: ST. ANNE'S HOME FOR ELDERLY
FACILITY NUMBER: 435294155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.

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 ensure that 2 of 5 non-ambulatory residents (R4 and R5) were living in rooms (Room #5 and Room #2 respectively) that had approved non-ambulatory fire clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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The licensee stated they will apply for non-ambulatory fire clearance for Room #2 for R5 and will contact R4's physician to get correct ambulatory status for R4 and will submit the evidence of approved/denied fire clearance and R4's correct ambulatory status to CCLD by 07/29/2025.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(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 ensure that 3 of 5 residents (R1-R3) received an annual routine visit with their physician, either is person or video appointment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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The licensee stated they will contact the physicians of these three Residents (R1-R3) to schedule annual visit and will submit the evidence of their appointment and physician reports to CCLD by 07/29/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2025 01:52 PM - It Cannot Be Edited


Created By: Kiran Jain On 07/22/2025 at 01:03 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: ST. ANNE'S HOME FOR ELDERLY
FACILITY NUMBER: 435294155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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 ensure that the Emergency Disaster Drills logs are conducted quarterly at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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The Licensee stated they will conduct Emergency disaster drills once every quarter and will submit a evidence of latest drill conducted to CCLD by 07/29/2025.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/22/2025 01:52 PM - It Cannot Be Edited


Created By: Kiran Jain On 07/22/2025 at 01:06 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: ST. ANNE'S HOME FOR ELDERLY
FACILITY NUMBER: 435294155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)(C)
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: (C) The drug name, strength and quantity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the Administrator did not ensure that a medication ‘Atorvastatin 80MG’ that was administered to 1 of 5 residents (R1)’s was entered in the Centrally Stored Medication Records, which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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The Licensee stated that they will review R1's medications, update Centrally Stored Medication Record for R1, and submit the evidence of corrected Centrally Stored Medication Record to CCLD by 07/23/2025.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
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