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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202894
Report Date: 06/21/2024
Date Signed: 06/21/2024 05:24:44 PM

Document Has Been Signed on 06/21/2024 05:24 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 3FACILITY NUMBER:
435202894
ADMINISTRATOR/
DIRECTOR:		GARCIA, RITAFACILITY TYPE:
740
ADDRESS:770 PRONTO DRTELEPHONE:
(408) 629-6178
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Rita Garcia - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 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
On 6/21/2024 at 1:20 p,m. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required 1 year inspection and was met by Administrator (ADM) Rita Garcia and stated the purpose of the visit.

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 6 residents that have mental illness and neurocognitive impairment. 1 of 2 staff were present at the time of the visit. 6 residents were present at the facility. out of 6 is under the age of 60, 6 out of 6 are-ambulatory, 2 out of 6 have mild neurocognitive impairment.

LPA and ADM 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 70 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.

page 1 of 2 (see LIC 809C)
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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 4
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 3
FACILITY NUMBER: 435202894
VISIT DATE: 06/21/2024
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
26
27
28
29
30
31
32
LPA inspected the residents' bedrooms and observed 4 out of 4 bedrooms 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 bathroom floors were scrubbed and sanitized. LPA observed the shower curtain in one of the bathroom has brown residue at the bottom. ADM stated the shower curtain will be replaced. During the tour, LPA observed that Bedroom #4 vertical window blinds were in disrepair. The planks were taped and 3 of the planks were split in half and taped together. ADM stated the licensee will be notified that the vertical blinds needs replacement.

LPA with ADM tested the water temperature for kitchen and bathrooms, water temperature was measured at 119.7 degree F.

LPA with ADM 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 6 resident records. The disaster training conducted on 6/10/2024. Residents files were complete and updated. Residents' medications are labeled and current. Staff record were up to date with certification and training.

LPA reviewed the facility resident roster and 2 out of 6 are under the age of 60. The facility did not submit an exception request and did not submit exception request licensing to admit and retain resident 2 (R2) who is under the age of 60.

Deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22, see LIC 809D. An exit interview was conducted with administrator (ADM) Rita A Garcia. A copy of the report and appeals rights were provided.
Page 2 of 2 end of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/21/2024 05:24 PM - It Cannot Be Edited


Created By: Maria Partoza On 06/21/2024 at 05:06 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 3
FACILITY NUMBER: 435202894

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87455(b)(7)
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above, 2 out of 6 residents under the age of 60. The facility has a census of 5 resident who is over the age of 60. ADM did not submit an exception request prior to admitting R2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
1
2
3
4
The administrator stated that he/she will submit 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.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/21/2024 05:24 PM - It Cannot Be Edited


Created By: Maria Partoza On 06/21/2024 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 FEELS RESIDENTIAL CARE 3
FACILITY NUMBER: 435202894

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
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
1
2
3
4
Based on observation the licensee did not comply with the section cited above in 1 out 1 objects. The licensee did not keep the resident's bendroom i in good repair at all times, the blinds in Bedroom 4 was falling apart and falling off the latch. Blind shade planks were cut in half and seucred by a tape, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2024
Plan of Correction
1
2
3
4
ADM stated the licensee will be notified that vertical window blinds in bedroom #4 requires replacement. ADM stated the plan of correction will be submitted to LPA by the due date
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4