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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202644
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:32:29 PM

Document Has Been Signed on 10/19/2023 12:32 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: 3DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Lead Staff, Imuentinyan IbinigieTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Lead Staff, Imuentinyan Ibinigie. LPA Rai observed 1 staff and 1 resident at the facility and 2 residents were attending day program. Licensee/ Administrator was notified of the visit but was not available for today's inspection.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

The facility bathroom had available soap, paper towels, and trash cans with lids. The shower had grab bars and non-skid mats. The water temperature in the bathroom faucet was recorded at 112.3F. The water temperature in the kitchen sink was 110.7F. Fire extinguisher was observed and inspected on October 20, 2022. S1 stated the company overseeing the fire system will stop by tomorrow to do the annual inspection for the fire extinguisher. Facility smoke detectors and carbon monoxide detectors were in working condition. 3 out of 3 resident bedrooms had available bedding, drawers, and functioning lights.

LPA Rai reviewed facility records for 3 residents. The facility did not maintain staff records and was not available for LPA Rai to review. S1 states the facility does not have a central administrative location where the staff records would be kept outside of the facility.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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 5
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: CARING HANDS RESIDENTIAL LIVING
FACILITY NUMBER: 435202644
VISIT DATE: 10/19/2023
NARRATIVE
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LPA Rai reviewed R2's medications and central stored medication records. LPA observed the 3 out of 3 resident's file contained a blank LIC 622 Centrally Stored Medication and Destruction Log which did not contain the necessary information. S1 stated he/she has not used the LIC 622 form to record resident's medications. During review of R2's medications, S1 kept 2 medications in the fridge which was unlocked and accessible to persons other than employees responsible for the supervision of the medication.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. One Technical Violation Note was provided during today's visit.

This report was reviewed with Lead Staff, Imuentinyan Ibinigie and a copy of the report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/19/2023 12:32 PM - It Cannot Be Edited


Created By: Simranjit Rai On 10/19/2023 at 11:55 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: CARING HANDS RESIDENTIAL LIVING
FACILITY NUMBER: 435202644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465(h)The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in R2's 2 medications were kept in the fridge unlocked and accessible to persons other than employees responsible for the supervision of the medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Lead Staff stated the facility will obtain a locked container to store the medications that need to be placed in the fridge and will submit a written plan of action and understanding of regulation by POC 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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/19/2023 12:32 PM - It Cannot Be Edited


Created By: Simranjit Rai On 10/19/2023 at 12:03 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: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465 (h) The following requirements shall apply to medications which are centrally stored: (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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3 resident's file contained a blank LIC 622 Centrally Stored Medication and Destruction Log which did not contain the necessary iinformation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Lead Staff stated the facility staff will complete the information on the LIC 622 Centrally Stored Medication and Destruction Log and submit a written plan of action and understanding of the regulation by POC date.
Type B
Section Cited
CCR
87412(g)
87412 (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 ouf of 1 staff file was not maintained at the facility and was not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Lead Staff stated the facilty will maintan the staff file at the facility and submit a written plan of action and understandig of the regulation by POC 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 5 of 5