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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294206
Report Date: 08/22/2025
Date Signed: 08/22/2025 12:36:09 PM

Document Has Been Signed on 08/22/2025 12:36 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:KIMBERLY'S ELDER KARE KOTTAGEFACILITY NUMBER:
435294206
ADMINISTRATOR/
DIRECTOR:		KENDALL HALLFACILITY TYPE:
740
ADDRESS:2770 MOORPARK AVENUETELEPHONE:
(408) 483-1029
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 6CENSUS: 3DATE:
08/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Elizabeth GonzalezTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year Visit and met with staff Elizabeth Gonzalez.

During visit, LPA toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the first aid kit and found it to be complete.

LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks were 112 F and 116 F.

LPA tested the smoke detectors in the hallways and in six out of six resident bedrooms. Each smoke detector functioned properly when tested. LPA tested one out of one carbon monoxide detector and it functioned properly when tested.

LPA toured six out of six resident bedrooms and found each bedroom to have working lights. All the occupied bedrooms had available bedding and clothing storage areas.

During visit, LPA observed that a sliding glass door did not completely close and lock and two staff were needed to open and close the sliding door. LPA observed a hole about 3 inches in diameter in one of the resident bedrooms. LPA toured the outside area and found the outdoor exits were clear of obstructions.

The Emergency Disaster Drill Log indicates the last disaster drill was conducted on 06/06/2025. 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: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2025
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: KIMBERLY'S ELDER KARE KOTTAGE
FACILITY NUMBER: 435294206
VISIT DATE: 08/22/2025
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LPA Marrufo reviewed three out of three resident records, including Centrally Stored Medication and Destruction Records. Resident R1 had the wrong prescription number for one medication.

LPA reviewed 5 staff records. Staff S1 was missing a Health Screening Form. S2 was missing a current first aid certification.

Advisory Notes were issued. See LIC9102 forms for more information.

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

LPA Marrufo requests that the following records be updated and sent to LPA Marrufo within 5 business days:

LIC500 Personnel Report
Current Liability Insurance Record
Emergency Disaster Plan

This report was reviewed with staff Elizabeth Gonzalez and a copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Maria Partoza
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2025 12:36 PM - It Cannot Be Edited


Created By: David Marrufo On 08/22/2025 at 11:54 AM
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: KIMBERLY'S ELDER KARE KOTTAGE
FACILITY NUMBER: 435294206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one of the facility sliding glass doors, which could not properly be locked or opened, and one out of six resident bedrooms, which had a hole in one of the walls, which poses a safety risk to persons in care.
POC Due Date: 08/23/2025
Plan of Correction
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Licensee agrees to submit a a Plan of Correction by POC Due Date stating how the licensee will repair the sliding glass door and the hole in one of the resident bedrooms. Once repairs are made, the licensee shall submit photographic evidence of the repairs.
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.
Maria Partoza
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
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