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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202876
Report Date: 04/11/2023
Date Signed: 04/12/2023 08:18:57 AM

Document Has Been Signed on 04/12/2023 08:18 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:FAMILY SENIOR CARE HOME IFACILITY NUMBER:
435202876
ADMINISTRATOR:BAUTISTA, ELIZABETHFACILITY TYPE:
740
ADDRESS:2898 GLEN FROST COURTTELEPHONE:
(408) 802-7727
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 4DATE:
04/11/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Administrator Elizabeth Bautista and Armando GubaTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Simi Rai and Trang Pham arrived unannounced to conduct a Post Licensing visit. LPAs met with Administrator Elizabeth Bautista and Armando Guba.

LPAs observed the following posters posted: If You See Something Say Something, Ombudsman, and residents rights to counsel. There is currently 4 residents living at the facility.

LPAs toured the facility inside and outside including the bedrooms, bathrooms, living room, and kitchen. Bedrooms and bathrooms were observed clean. Bedrooms are equipped with proper furniture. Facility is equipped with lights and comfortable light lighting. Bathrooms are equipped with grab bars and nonskid floor. Hygiene items and toiletries are available to the residents. Hot water temperature is maintained at 105.0 degrees Fahrenheit. Centrally stored medications, toxins, and sharp objects were locked and inaccessible to the residents. 2 days worth of perishable food and 7 days worth of nonperishable food were observed. Freezers and refrigerators were observed clean.

Facility is equipped with smoke detectors and carbon monoxide detector. Hallways and passageways are free of obstruction.

LPAs reviewed 4 out of 4 resident records. Resident's mediations were compared with medication log and physician's order. LPAs observed a printed list of medications which was not signed by a physician. Per (ADM), R3 was admitted at a skilled nursing facility and the family provided the list. Per staff S1, medication has been followed on R3's medication log and S1 and S2 have been initialling the medication log which verifies the medication was given to the resident. S1 stated the medication was given by S1 on the dates with S1's initials.

Continued on Page 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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 04/12/2023 08:18 AM - It Cannot Be Edited


Created By: Simranjit Rai On 04/11/2023 at 05:03 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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
87465 Incidental Medical and Dental Care
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 4 resident records contained a medication list which not was signed by a physician, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2023
Plan of Correction
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Licensee will submit a signed medication list for resident (R3) by POC date. Licensee will provide medication training to staff and provide the training log to LPA Rai 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: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2023 08:18 AM - It Cannot Be Edited


Created By: Simranjit Rai On 04/11/2023 at 05:09 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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 staff did not have chest x-ray or an intradermal test not more than 6 months prior or 7 days after employment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2023
Plan of Correction
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Licensee will obtain chest X-Ray or an intradermal test for S1 and S2 and submit the results to LPA Rai 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: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876
VISIT DATE: 04/11/2023
NARRATIVE
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LPAs reviewed 2 out of 2 staff records. LPAs observed the health screening report was incomplete since the TB test results was not provided on the report. There was a chest X-Ray from 2021 for S1 which was not within 6 months of hire date. Per ADM, the hire date for S1 is 3/21/2023.

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

This report was reviewed with Administrator Elizabeth Bautista and a copy of this report provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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