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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202749
Report Date: 03/22/2023
Date Signed: 03/22/2023 05:45:15 PM

Document Has Been Signed on 03/22/2023 05:45 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:CARING HANDS RESIDENTIAL LIVING IIFACILITY NUMBER:
435202749
ADMINISTRATOR:OKORO, SYLVESTER OFACILITY TYPE:
740
ADDRESS:1324 BAGELY WAYTELEPHONE:
(614) 747-3443
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: DATE:
03/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Abijaun BurchellTIME COMPLETED:
04:44 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 03/22/2023 at 01:32pm. LPA met with facility staff member Abijaun Burchell (S1). S1 contacted the facility administrator Sylvester Okoro (Admin). Admin stated that he would not be able to attend the inspection in person and gave S1 permission to conduct the inspection/sign reports in his stead.

LPA toured the facility, including kitchen, living room, staff room, 2 bathrooms, 4 resident rooms, garage, and back yard. S1 confirmed that all staff and residents have been vaccinated. All residents and staff have received their booster shots as well. Facility infectious control plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Facility water temperature measured at 110*F. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in October 2022. Smoke/carbon monoxide detectors tested and observed to be operational.

All staff members present at the facility were observed to be fingerprint cleared on Guardian. LPA reviewed 4 out of 4 resident files, all resident files were observed to be incomplete and and out of date. 0 out of 4 files contained a physician's report less than a year old. 0 out of 4 files contained a completed needs and services assessment. 4 out of 4 files contained completed admissions agreements. S1 called Admin to inquire about up to date documents. Admin stated that he has up to date digital copies, but that he was not at his computer and needed about an hour to send the documents. LPA did not receive the documents.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749
VISIT DATE: 03/22/2023
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LPA attempted to contact the administrator two hours later, at 03:42pm and 04:04pm, but was unable to reach him. At the time of this writing, LPA has still not received up to date documentation from the Admin.

Deficiencies cited during today's visit. This report was reviewed with facility staff member Abijaun Burchell, who signed on behalf of Administrator Sylvester Okoro and a copy of the signed report was provided digitally due to printer error.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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Document Has Been Signed on 03/22/2023 05:45 PM - It Cannot Be Edited


Created By: Ryker Heberle On 03/22/2023 at 04:36 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 II
FACILITY NUMBER: 435202749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(d)
d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reivew, the licensee did not comply with the section cited above, as 4 out of 4 files were observed as incomplete and administrator was not able to provide up to date copies in a timely manner which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2023
Plan of Correction
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Licensee to update all paper facility files with up to date information, and provide proof of completed files to LPA 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:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023


LIC809 (FAS) - (06/04)
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