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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294315
Report Date: 01/15/2026
Date Signed: 01/15/2026 04:17:34 PM

Document Has Been Signed on 01/15/2026 04:17 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:KEENE KARE IIIFACILITY NUMBER:
435294315
ADMINISTRATOR/
DIRECTOR:		GAMBOA, ABIGAILFACILITY TYPE:
740
ADDRESS:4629 ROYAL FOREST COURTTELEPHONE:
(408) 616-0615
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 4DATE:
01/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Licensee Cristina BanagoTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Licensee (LN) Cristina Banago. During the visit, LPA observed 4 residents and 2 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 4 residents bedrooms. There was no obstruction to block the walkways. The staff area of the facility was also inspected. The front yard and backyard were inspected.

While touring resident bedroom, located between 2 residents bedroom, LPA noted, oxygen was being used. ADM confirmed the resident that was residing in that bedroom does use oxygen. LPA noted that the door to the bedroom does not have a, "oxygen in use, no smoking."

LPA spoke to Administrator and noted to Administrator Abigail Gamboa that she wasn't associated to the facility.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 118 degrees F in resident bathrooms.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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: KEENE KARE III
FACILITY NUMBER: 435294315
VISIT DATE: 01/15/2026
NARRATIVE
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Fire extinguisher was serviced in March 13, 2025. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by LN, and were functional. LPA observed facility first aid kit. LPA requested to review the facility emergency drill log. Licensee Cristina Banago stated she and the ADM have not conducted any drills.

LPA reviewed requested to review staff records. LN stated she didn't have them prepared for LPA to review.

LPA reviewed 3 resident files. Resident R2's Needs and services plan is dated August 10, 2024, is blank. Resident R3's Needs and Services Plan is blank. Resident R3's Pre-admission Appraisal is blank. LN stated she didn't do a pre-admission appraisal for R3.

LPA reviewed 3 resident medications and centrally stored medication records. Resident R1's centrally stored medication record did not have 5 of R1's medications listed. Resident R4 did not have 2 medications that were not listed in his/her centrally stored medication record. Resident R3 did not have his/her medications listed on his/her centrally stored medication record.

A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for the Administrator working in the facility without association.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Cristina Banago and a copy of the signed report was provided. Appeal rights were provided.

END OF REPORT.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 01/15/2026 04:17 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/15/2026 at 03:22 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: KEENE KARE III
FACILITY NUMBER: 435294315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Licensee stated she did not have staff files available for LPA to review. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2026
Plan of Correction
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Licensee / ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send to LPA by POC due date, January 22, 2026
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Facility Administrator is not associated with the facility. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2026
Plan of Correction
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Licensee / Administrator will associate the Administrator to the facility. Licensee/ Administrator will send letter of understanding regarding the regulation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 01/15/2026 04:17 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/15/2026 at 03:22 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: KEENE KARE III
FACILITY NUMBER: 435294315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Licensee stated she did not preform a pre admission appraisal for R3. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2026
Plan of Correction
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ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send to LPA by POC due date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Resident R2's Needs and services plan is dated August 10, 2024, is blank. Resident R3's Needs and Services Plan is blank. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2026
Plan of Correction
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ADM / Licensee stated she will send LPA a copy of R2 and R3's updated Needs and services plan by POC due date. ADM / Licensee stated she will send a letter of understanding regarding the regulation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 01/15/2026 04:17 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/15/2026 at 03:22 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: KEENE KARE III
FACILITY NUMBER: 435294315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

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 interview, the licensee did not comply with the section cited above. Licensee stated she and the Administrator have not conducted quarterly drills. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2026
Plan of Correction
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ADM stated she will conduct a disaster drill and will ensure the Documentation of the drill shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. ADM stated she will send documentation a drill has taken place to LPA by POC due date.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

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. located between 2 residents bedroom, LPA noted, oxygen was being used. ADM confirmed the resident that was residing in that bedroom does use oxygen. LPA noted that the door to the bedroom does not have a, "oxygen in use, no smoking." This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2026
Plan of Correction
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ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will put a "oxygen in use, no smoking" sign in the room that is using oxygen and send photo documentation showing the sign is in place. ADM stated she will send to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 01/15/2026 04:17 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/15/2026 at 03:48 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: KEENE KARE III
FACILITY NUMBER: 435294315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h) (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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the licensee did not comply with the section cited above. Resident R1's centrally stored medication record did not have 5 of R1's medications listed. Resident R4 did not have 2 medications that were not listed in his/her centrally stored medication record. Resident R3 did not have his/her medications listed on his/her centrally stored medication record. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2026
Plan of Correction
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ADM stated she will send an updated Centrally stored medication record for residents R1, R3 and R4. ADM stated she will send to LPA by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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