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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202643
Report Date: 10/25/2024
Date Signed: 10/25/2024 04:45:59 PM

Document Has Been Signed on 10/25/2024 04:45 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:AMY'S RESIDENTIAL CARE, INC.FACILITY NUMBER:
435202643
ADMINISTRATOR/
DIRECTOR:		SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:671 N WHITE RDTELEPHONE:
(408) 898-8784
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
10/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Amarjeet MannTIME VISIT/
INSPECTION COMPLETED:
01:32 PM
NARRATIVE
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The purpose of this visit is to amend the complaint report for complaint number 26-AS-20230314081243 delivered on 09/18/2024.

Based on a complaint investigation, when resident R1 sustained an injury to his/her left eye, the facility did not submit an incident report LIC624 to community licensing office within 7 days after the occurrence of the incident. See LIC809-D.

An exit interview was conducted with Administrator (ADM) for review and signature of this report. A copy of this report was provided to ADM. Appeal rights was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/25/2024 04:45 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 10/24/2024 at 03:42 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: AMY'S RESIDENTIAL CARE, INC.
FACILITY NUMBER: 435202643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as....(1) A written report shall be submitted to the licensing agency ...within seven days of the occurrence of the events ...(D)Any incident which threatens the welfare, safety or health of any resident,
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Administrator stated he/she will to submit plan of correction by the POC due date to ensure the facility staff to send the incident report to community licensing office within 7 days of the occurrence of incidents..
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This requirement was not met as evidenced by:
Based on the interviews and records reviewed, the facility did not submit R1's incident report to community licensing office when R1 sustained eye injury on 2/14/2023 or 2/15/2023 which poses a potential health, and safety risk to persons in care.
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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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


LIC809 (FAS) - (06/04)
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