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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202644
Report Date: 10/19/2022
Date Signed: 10/19/2022 04:28:08 PM

Document Has Been Signed on 10/19/2022 04:28 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:CARING HANDS RESIDENTIAL LIVINGFACILITY NUMBER:
435202644
ADMINISTRATOR:OKORO, SYLVESTERFACILITY TYPE:
740
ADDRESS:3590 ROLLINGSIDE DRTELEPHONE:
(408) 440-0200
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 1DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Imuentinyan IbinigieTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the annual inspection focusing on infection control. LPA met with staff, Imentinyan Ibinigie.

During visit, LPA toured the facility to include the living room, kitchen, resident rooms, bathrooms, and backyard.

Facility has a designated entry point for temperature check and sign-in. LPA advised to place a symptom screening questionnaire at the entry for all visitors and staff. Hand sanitizer available at entry. Visitation guidelines posted at entry. Staff clean and disinfect multiple times daily and as needed. Bathrooms supplied with hand washing sign, paper supplies, and hygiene products. Facility has procedures to isolation. Staff states to have conducted infection control training. LPA did not observe at least a 30 day supply of complete Personal Protective Equipment (PPE) supplies. Trash can with lid observed. Staff are not N95 fit tested. The following posters observed to include symptoms of COVID, hand washing, and stop the spread of germs.

Facility's fire extinguisher was last serviced on 10/02/2020.

The following documents were requested during visit to include facility's LIC-500 and LIC610E by 10/21/2022.

A deficiency is being cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Imentinyan Ibinigie and a copy of the report and appeal rights will be emailed to the Administrator due to printer error.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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Document Has Been Signed on 10/19/2022 04:28 PM - It Cannot Be Edited


Created By: Christine Dolores On 10/19/2022 at 03:58 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: CARING HANDS RESIDENTIAL LIVING
FACILITY NUMBER: 435202644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, observation, and record review the licensee did not ensure to service the fire extinguisher annually which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2022
Plan of Correction
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Licensee states to get the fire extinguisher serviced tomorrow and will send a picture of the service tag to LPA via email by POC due date.
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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022


LIC809 (FAS) - (06/04)
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