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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202736
Report Date: 01/25/2024
Date Signed: 01/25/2024 10:50:15 AM

Document Has Been Signed on 01/25/2024 10:50 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:KINGDOM HEARTS CARE HOMEFACILITY NUMBER:
435202736
ADMINISTRATOR:ABLAN, RYAN MFACILITY TYPE:
740
ADDRESS:3633 HEATHCOT COURTTELEPHONE:
(408) 262-0425
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator Annabelle AblanTIME COMPLETED:
10:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met Administrator (ADM) Annabelle Ablan . During visit, LPA observed 3 residents and 2 staff.

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 2 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 112 degrees F in both resident bathrooms.

Fire extinguisher was serviced in May 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 2023.

LPA reviewed facility records for 3 staff and 3 residents. While reviewing resident R1 and R2's records, LPA observed their needs and services plans were not filled out and were empty. (Photographs were taken.) ADM stated she forgot to fill out the forms. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff (S1) and 2 residents (R1-R2).

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Annabelle Ablan. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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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Document Has Been Signed on 01/25/2024 10:50 AM - It Cannot Be Edited


Created By: Manuel Monter On 01/25/2024 at 10:29 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: KINGDOM HEARTS CARE HOME

FACILITY NUMBER: 435202736

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/25/2024

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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Based on record review and interview, the licensee did not comply with the section cited above in 2 out of 3 resident records reviewed. While reviewing resident R1 and R2's records, LPA observed their needs and services plans were not filled out and were empty. ADM stated she forgot to fill out the forms. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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ADM stated she will update both residents needs and services plan. ADM stated she will send LPA documentation that the needs and services plan has been updated. ADM stated she will send letter of understanding regarding the regulation. ADM stated she will send to LPA by POC date, 2/01/2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
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