435202891-8-30-2026-26-AS-MPAA-DXFQ8E-20260830115637

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202891
Report Date: 08/26/2026
Date Signed: 08/30/2026 11:58:21 AM

Document Has Been Signed on 08/30/2026 11:58 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:	RGK HOME CARE		FACILITY NUMBER:	435202891
ADMINISTRATOR/ DIRECTOR:	CRUZ, RAVENAL DE GUZMAN		FACILITY TYPE:	740
ADDRESS:	274 CLEARPARK CIRCLE		TELEPHONE:	(408) 420-7262
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY: 6		CENSUS: 6	DATE:	08/26/2026
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:40 PM
MET WITH:	Mary Grace Lazaro		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

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 08/26/2026, Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Case Management–Noncompliance Monitoring visit. Upon arrival, LPA was greeted by three staff. The licensee/administrator Mary Grace Lazaro and Ravenal Cruz was not present at the facility at the time of the inspection and arrived at the facility approximately 10 minutes after LPAs arrival. The facility remains under increased monitoring pursuant to the Compliance Plan established during the Noncompliance Conference conducted on December 3, 2024. The Compliance Plan requires monitoring inspections every three months for two years. This visit represents the second-to-last monitoring visit within the two-year monitoring period. The purpose of the visit was to evaluate the facility’s implementation of the Compliance Plan addressing care and supervision, facility security, resident reappraisals, staff training, acceptance and retention, collaboration with responsible persons and involved agencies, licensee and administrator accountability, incident reporting, staffing, and nighttime supervision. At the time of the visit, 3 out of 6 residents and 3 staff were present. One resident was hospitalized and 2 arrived from the day program after 4:30 p.m. page 1

Romeo Manzano
Maria Partoza
	DATE: 08/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026

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: RGK HOME CARE	FACILITY NUMBER: 435202891
	VISIT DATE: 08/26/2026

NARRATIVE

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LPA toured the facility’s interior and exterior areas and inspected the front exit, rear exit, and side exit located in a resident bedroom. LPA tested the alarm on each of the three exits. Each alarm produced an audible chime when the corresponding door was opened. From a distance, the chime could be heard; however, the specific door being opened was not readily distinguishable. When LPA moved closer to the alarm system, the announcement identifying the activated door was understandable.

LPA interviewed three staff regarding resident supervision, scheduled resident checks, staffing coverage, door-alarm response, missing-resident procedures, incident reporting, and staff training. Three of three staff stated no current resident demonstrated active elopement, wandering, or exit-seeking behavior. Staff stated they reviewed residents’ Individual Program Plans, appraisals, needs and services plans, medical information, and other records to identify residents’ care and supervision needs.

Three of three staff stated they would check the applicable exit when a door alarm activated. Staff stated the alarms could be heard throughout the facility; however, one of three staff stated the alarm announcement could be difficult to understand when the facility was noisy. Two of three staff stated alarms were tested weekly, while one of three staff identified the administrator as responsible for testing the alarms but did not identify the testing frequency. One of three staff recalled a prior occasion when part of the rear-door alarm became displaced and the alarm did not activate until staff identified and corrected the problem.

Staff provided inconsistent information regarding scheduled resident checks. One of three staff described daily body checks and hourly nighttime checks, one of three staff stated residents were checked every 15 minutes, and one of three staff described frequent or daily checks without identifying the required frequency. Staff stated incomplete checks were communicated to the following shift. The interviews did not establish a consistent understanding of which residents required scheduled supervision checks or how missed checks and residents’ absences from the facility were documented.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026

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: RGK HOME CARE	FACILITY NUMBER: 435202891
	VISIT DATE: 08/26/2026

NARRATIVE

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Three of three staff stated they would search the facility and surrounding areas and notify the administrator if a resident could not be located. Staff provided different responses regarding when 9-1-1 or law enforcement would be contacted. One of three staff stated staff might wait approximately 30 minutes to one hour, one of three staff stated law enforcement would be contacted when staff could not locate the resident, and one of three staff stated law enforcement would not be contacted immediately and the administrator would be notified first.

Three of three staff stated an incident report would be completed following an elopement or missing-resident incident. Staff identified the administrator as responsible for submitting the report to Licensing. Staff did not consistently identify all required notifications, reporting time frames, resident reassessment, revision of the resident’s supervision plan, or other follow-up actions following the resident’s return.

Staff also provided inconsistent information regarding staffing and the person designated to be in charge when the licensee/administrator was absent. Staff identified different persons as the designated person in charge. One of three staff stated at least two staff were always present, one of three staff stated the staff member was alone with six residents after approximately 5:00 p.m., and one of three staff stated four staff worked each shift and stated that he/she did not work alone.

Three of three staff reported receiving training or instruction related to resident care, behavioral needs, missing-resident procedures, elopement, or incident reporting. Staff did not consistently describe the content of the training or demonstrate a consistent understanding of the facility’s procedures regarding staffing, scheduled resident checks, chain of command, emergency notifications, and follow-up after an elopement or missing-resident incident.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026

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: RGK HOME CARE	FACILITY NUMBER: 435202891
	VISIT DATE: 08/26/2026

NARRATIVE

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LPA reviewed 3 out of 6 residents’ records, including Individual Program Plans, appraisals, needs and services plans, progress notes, and resident-checking logs. The records were reviewed determine that residents’ current supervision needs, scheduled checks, known behaviors, resident-specific interventions, and staff responsibilities were documented and updated following incidents or changes in condition.

LPA reviewed the current LIC 500 Personnel Report, staff schedules, time records, and shift assignments for month of August 2026. The records were reviewed determined that staffing was maintained during all shifts, including nighttime hours.

LPA reviewed staff training records, training materials, attendance records, and alarm-testing records. The records were reviewed and determine that staff received the training required by the Compliance Plan, that the facility regularly tested its alarms, and when alarm malfunctions a corrective actions were documented.

LPA reviewed incident reports and notification records from May 2026 through August 26, 2026. The records were reviewed determined that incidents were reported to the Department within the required time frames, and responsible persons and other involved agencies were notified, and residents were reassessed following incidents or changes in behavior are monitored.

Based on observations, interviews, and records reviewed, the facility was found to be in compliance with the December 3, 2024 Noncompliance Conference Compliance Plan. Staff responses varied regarding scheduled checks, staffing, the designated person in charge, and missing-resident procedures. The licensee/administrator was advised to review these procedures with all staff to ensure consistent implementation.

No deficiencies were cited during today’s visit. An exit interview was conducted with Mary Grace Lazaro and Ravenal Cruz and a copy of the report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026

LIC809 (FAS) - (06/04)

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