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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202668
Report Date: 02/13/2024
Date Signed: 02/13/2024 04:28:16 PM

Document Has Been Signed on 02/13/2024 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:AT HOME SENIOR CARE IFACILITY NUMBER:
435202668
ADMINISTRATOR:SAZON, DEBBIEFACILITY TYPE:
740
ADDRESS:819 GAIL AVETELEPHONE:
(408) 738-1400
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 6CENSUS: 6DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Debbie SazonTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mita Partoza conducted an unannounced annual inspection at the facility. LPA met with administrator (ADM) Debbie Sazon and two staff.

Current census 6 residents and 4 out 6 have neurocognitive disorder.

During visit, LPA toured the facility to include the living room, dining room, kitchen, 7 bedrooms, including staff room and 6 resident's bedrooms. 3 bathrooms, garage, and backyard. The bathroom hot water temperature was measured at 113.4 degrees Fahrenheit to 120.2 degrees Fahrenheit. The kitchen water temperature is within range of 125 degree Fahrenheit. The room temperature in the facility ranges from 68 degree Fahrenheit to 75 degree Fahrenheit.

LPA observed 2 days of perishable and 7 days non-perishable food supply as required by regulation.
Toiletries such as toilet paper, paper towels, toothpaste are inspected and found to be in ample supply.
Toxic materials such as laundry detergent, disinfectant are inaccessible to residents that are in a locked cabinet. Hallways have night lights and have ample lighting.

LPA toured the facility and observed emergency exits and walkways are clear of obstruction and lawn is well maintained.

continued on page 2 (LIC 809C)
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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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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: AT HOME SENIOR CARE I
FACILITY NUMBER: 435202668
VISIT DATE: 02/13/2024
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continued from page 1 of LIC 809

LPA tested the carbon monoxide and the smoke alarm and found them to be in good working condition.

LPA randomly reviewed 3 resident's record (R1 to R3) R1 and R3 needs and appraisal plan is missing and R2 needs to be updated. LPA reviewed R1 to R3's centrally stored medication and destruction record (CSDMR) and found no discrepancy

LPA randomly reviewed 3 staff record and observed that training are up to date, including the emergency disaster plan..

Deficiencies were cited per California Code of Regulations, Title 22 during today's visit. This report was reviewed with administrator Debbie Sazon.


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End of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 02/15/2024 11:40 AM


Created By: Maria Partoza On 02/13/2024 at 03:33 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: AT HOME SENIOR CARE I
FACILITY NUMBER: 435202668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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This is an amended report for visit cited on 2/13/2024.
Based on record review, the licensee did not comply with the section cited above, licensee did not complete a re-appraisal for 2 out of 3 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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License stated that she will complete the Appraisal needs and services plan to keep the record accurate and changes will be documented accordingly for resident's physical, medical, mental and social condition. LIcensee stated she understodd.
Type B
Section Cited
CCR
87507(l)
Admission Agreements
(l) The licensee shall attach a copy of applicable resident's rights specified by law or regulation to all admission agreements, and shall include information on the reporting of suspected or known elder and dependent abuse, as set forth in Health and Safety Code Section 1569.889.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This is an amended report for visit cited on 2/13/2024.
Based on record review, the licensee did not comply with the section cited above, licensee did not have a signed personal rights in the resident's file/record for 1 out 3 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Licensee stated that she will ask the responsible party (RP) for the signed resident's rights. If RP states he/she cannot find the document she will have another one signed by the RP. Licensee stated she understood
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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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