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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202893
Report Date: 06/07/2024
Date Signed: 06/07/2024 08:15:45 PM

Document Has Been Signed on 06/07/2024 08:15 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:FAMILY FEELS RESIDENTIAL CARE 2FACILITY NUMBER:
435202893
ADMINISTRATOR/
DIRECTOR:		SHIH, YIWENFACILITY TYPE:
740
ADDRESS:777 TERRAZZO DRIVETELEPHONE:
(408) 972-0125
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 3DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Rita A. Garcia - Designated AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
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On 6/07/2024 at 2:45 p,m. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Required annual inspection and was met by Designated Administrator (DADM) Rita Garcia. The Administrator(ADM) Yiwen (NIcole) Shih was not present at the time of the visit. DADM called ADM and asked if LIC/ADM can come to the facility. LIC/ADM stated he/she is not available due to prior commitment.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over, capacity for 6 ambulatory of which 6 may be non-ambulatory and 6 hospice waiver. The facility has 3 residents that are neurocognitive impaired. 1 out of 2 staff were present at the time of the visit. 3 residents were present at the facility. 2 out of 3 are under the age of 60, 1 out 3 is non-ambulatory, 2 out of 3 are ambulatory, 3 out 3 have neurocognitive impairment.

LPA and DADM toured the facility inside and outside, including but not limited to the following: Kitchen, dining, laundry, garage, 4 resident room, 1 staff room, 2 bathrooms, backyard and the exterior walkways.

LPA observed the Personal Rights disclosure, Long Term Care Ombudsman (LTCO) and Centralized Complaint and Information Bureau (CCIB) of the CA Department of Social Services (CDSS) prominently posted on the wall, visible to visitors, resident and staff. The temperature inside the home was at 69 to 71.1 degrees F.

LPA observed the kitchen to be organized, and sanitary with working appliances. Knives were kept in a secure locked area and not easily accessible to residents. The laundry area is located in the garage, cleaning supplies and laundry detergents are kept in a secure locked place not easily accessible to residents in care. The facility has 2 days of perishable food and 7 days of non-perishable food.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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: FAMILY FEELS RESIDENTIAL CARE 2
FACILITY NUMBER: 435202893
VISIT DATE: 06/07/2024
NARRATIVE
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LPA inspected the residents' bedrooms and found that 4 out of 4 rooms have furniture and closet space for resident's personal belongings, bed frames with mattress and bed linens. 4 Out of 4 resident room is sanitary, organized and are free from debris. LPA observed that the 1 Out of 2 bathrooms have rust on the floor of the shower and tub combination, stains on the toilet bowls, sink, faucet, trash bins and the floor.

LPA with ADM tested the water temperature for kitchen and bathrooms, water temperature was measured at 105.6 degrees F to 113 degree F.

LPA with DADM inspected the laundry area and observed washer and dryer are in good working condition. LPA observed that the medication is in a locked cabinet. The facility has a first aid cabinet with first aid supplies and accessible to staff.

The side door and sliding door to access the backyard opens easily and are free from obstruction. LPA observed ramps and walkways are free from obstruction. LPA observed the backyard area to be free from debris and is maintained. The facility is in a compound with two other facility under the same ownership.

LPA reviewed facility record and 2 out of 2 staff record, and 3 out of 3 resident records. The disaster training has not been conducted since the facility got licensed on 6/16/2023. 2 out of 2 does not have a CPR training, 2 out of 2 staff does not have on boarding training, 1 out 2 recently started with employment. Residents files were reviewed to be complete. Residents' medications are labeled and current.

LPA discussed with DADM the importance of fire and earthquake training and the required training for the staff that was recently hired.



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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
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 FEELS RESIDENTIAL CARE 2
FACILITY NUMBER: 435202893
VISIT DATE: 06/07/2024
NARRATIVE
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During document review and observation, LPA observed that 2 out of 3 of the resident (R1 and R2) were under the age of 60 and facility did not submit an exception request and notify licensing to admit and retain residents under the age of 60.

LPA requested documents from DADM such as, LIC 500, lease agreement, updated liability insurance and LIC 308 to update the facility record.

LPA discussed with DADM the Summer Wellness Preparedness Readiness that is available online for the DADM and LIC/ADM to discuss and train staff.

Deficiencies are cited during today's visit based on the California Code of Regulations (CCR) Title 22, see LIC 809D. An exit interview was conducted with designated administrator (DADM) Rita A Garcia. A copy of the report and appeals rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/07/2024 08:15 PM - It Cannot Be Edited


Created By: Maria Partoza On 06/07/2024 at 05:42 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 FEELS RESIDENTIAL CARE 2
FACILITY NUMBER: 435202893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)(1)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by not maintaining the facility in good repair such as the upkeep of 1 out of 2 resident bathroom. The bathroom tub floor has rust, the floor caulking is peeling behind the toilet seat, sink, and under the toilet seat, the drawer pull is coming off, and hard water on the faucet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2024
Plan of Correction
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Licensee/administrator will submit a plan on how maintenance of the resident bathroom will be addressed and when maintenance will be scheduled in accordance to the well being of residents, employees and visitors.
Type A
Section Cited
CCR
87405(d)(1)(2)
87405 Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review the licensee did not comply with the section cited above by not exhibiting understanding of the requirement and applicable, rules, & regulations. LIC/ADM accepted R1 & R2 without notifying and requesting for exception to licensing, did not administer proper training to direct care staff. LIC/ADM did not conduct disaster training since 6/16/2023,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2024
Plan of Correction
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LIC/ADM shall submit to LPA schdule of staff training, care and supervision of residents, maintenance of the facility and understanding the regulations for the safety of residents, staff and visitors.
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: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/07/2024 08:15 PM - It Cannot Be Edited


Created By: Maria Partoza On 06/07/2024 at 06:37 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 FEELS RESIDENTIAL CARE 2
FACILITY NUMBER: 435202893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87455
87455 Acceptance and Retention Limitations (b) The following persons may be accepted or retained in the facility: (7) Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility. This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, R1 and R2 are both under the age of 60. The facility has a census of 1 resident who is over the age of 60. ADM did not send exception request prior to admitting the R1 and R2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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The Licensee/Administrator stated that he/she plans to move R1 and R2 to one of the facility to comply with the regulation without submitting an exception request in compliance with the 25% under age resident allowed by the regulation in an RCFE facility. The plan will be submitted to LPA by the due date.
Type B
Section Cited
CCR
87412
87412 Personnel Records (c) Lcensees shall maintain in the personnel records ... required staff training and orientation.
(1) The following staff training and orientation shall be documented: (A)For staff who assist with personal activities of daily living, (B)For staff who provide direct care to residents ...: 1. The orientation received as specified in Section 87707(a)(1).
2. The in-service training received as specified in Section 87707(a)(2). This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not administering rquired training to S1 and S2 as direct care staff for resident in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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LIC/ADM shall submit the required training plan for S1 and S2 as direct care staff for resident.
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: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
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