<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202779
Report Date: 11/26/2024
Date Signed: 11/26/2024 04:46:33 PM

Document Has Been Signed on 11/26/2024 04:46 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:REAL ELDERLY CAREFACILITY NUMBER:
435202779
ADMINISTRATOR/
DIRECTOR:		ARIES GERONIMOFACILITY TYPE:
740
ADDRESS:4858 POSTON DRIVETELEPHONE:
(408) 440-2441
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 6DATE:
11/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:JANET SALVADORTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
The purpose of this visit was to amend the Case Management -Incident issued on 11/5/2024 wherein the Department inadvertently did not issue a deficiency on the medication error reported on 10/30/2024.

Please see LIC809-D for the deficiency.

Appeal Rights attached.

Exit interview was conducted with House Manager (HM). the report was provided to HM for review. A copy of the report was provided to HM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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 2
Document Has Been Signed on 11/26/2024 04:46 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 11/26/2024 at 12:08 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: REAL ELDERLY CARE
FACILITY NUMBER: 435202779

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/27/2024
Section Cited
CCR
87465(a)(4)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care. (a) ...shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
1
2
3
4
5
6
7
Licensee stated to submit a plan of correction by the POC due date to ensure staff to provide necessary supervision when administering medication to residents, and provide the staff training log of medication care training and providing care and supervision training.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Based on the interview and record reviewed, the facility staff were lack of supervision and resulted in resident R1 took resident R2's medications which poses/posed an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2