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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430702974
Report Date: 06/14/2024
Date Signed: 06/14/2024 01:29:57 PM


Document Has Been Signed on 06/14/2024 01:29 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:ESTHER'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
430702974
ADMINISTRATOR:IGNACIO, ESTHERFACILITY TYPE:
740
ADDRESS:1224 BENT DRIVETELEPHONE:
(408) 559-0681
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:6CENSUS: 5DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Licensee Vivencio IgnacioTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Licensee (LN) Vivencio Ignacio. During the visit, LPA observed 5 residents and 2 staff.

When the LPA entered the home, LPA asked for the staff members names. Staff S2 identified him/herself but his/her name did was not on the facility personnel Report Summary (LIS536). S2 stated he/she has been working at the facility for 3 weeks. LPA searched S2 on guardian and S2 is fingerprint cleared, but not associated to the facility.

LPA toured the facility inside out with LN which included the Living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the backyard, LPA observed some wooden planks, near bedroom #1's sliding screen door, in the backyard deck had openings. (Photographs taken.) LN stated he has been getting estimates from contractors to address the hole in the wooden planks. LN stated he was planning on fixing the damaged wooden planks by the end of next week.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 116 degrees F in resident bathrooms.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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 5


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: ESTHER'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 430702974
VISIT DATE: 06/14/2024
NARRATIVE
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Fire extinguisher was serviced in July 16, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by LN, and were functional. LPA observed facility first aid kit. LPA requested to review the facility disaster drill log. LN stated the last drill conducted was on November 2023. LN stated he does not have a disaster drill log.

LPA reviewed facility records for 3 staff and 3 residents. LPA conducted interviews with 2 staff and 2 residents. LPA requested to review Staff S2's training. LN stated S2 has not completed any training yet. LN stated he does not have any documentation of training for S2 either. LN stated S2 has been working at the facility since June 1st, 2024.

LPA requested to review resident R1-R3's medications alongside their Centrally stored Medication Log. R1 and R2's Centrally stored Medication log is blank. Resident R3's centrally stored medication log states the latest medication start date is from April 27, 2022. (Photographs taken.) Facility ADM stated she has not updated the residents R1-R3's centrally stored medication log. ADM stated she still needs to fill out the forms and put the medications on the forms for 2024.

LPA requested a copy of the following documents to be sent to the Department by June 21, 2024.
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. LIC200, please update (i.e., new phone numbers etc), if necessary.
6. Qualifications of Administrator (Certificate)
7. Please review your facility program for updates (incorporating new laws and/or regulations)
8. Please submit copy of surety bond

Deficiencies are being cited during today's visit, see LIC809-D. This report was reviewed with Licensee Vivencio Ignacio and a copy of the signed report was provided. Appeal rights were provided.

END OF REPORT
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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/14/2024 01:29 PM - It Cannot Be Edited

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: ESTHER'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 430702974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

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. LPA requested to review Staff S2's training. LN stated S2 has not completed any training yet. LN stated he does not have any documentation of training for S2 either. LN stated S2 has been working at the facility since June 1st, 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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ADM stated she will train S2 and send documentation showing S2 has been trained. ADM stated she will also send a letter of understanding regarding the regulation. ADM stated she will send the plans of correction to LPA by POC date, June 21, 2024.

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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 06/14/2024 01:29 PM - It Cannot Be Edited

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: ESTHER'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 430702974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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. LPA requested to review the facility disaster drill log. LN stated the last drill conducted was on November 2023. LN stated he does not have a disaster drill log. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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ADM stated she will conduct a fire drill by POC date and send LPA documentation that a drill has taken place. ADM stated she will send the plan of correction by POC date, June 21, 2024.
Type B
Section Cited
CCR
87355(e)(2)
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

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, Staff S2 was not on the facility personnel Report Summary (LIS536). S2 stated he/she has been working at the facility for 3 weeks. LPA searched S2 on guardian and S2 is fingerprint cleared, but not associated to the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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ADM stated she will associate S2 by POC date, June 21, 2024. ADM stated she will also send a letter of understanding regarding the regulation. ADM stated she will send the letter by POC date, June 21, 2024.
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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 06/14/2024 01:29 PM - It Cannot Be Edited

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: ESTHER'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 430702974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. R1 and R2's Centrally stored Medication log is blank. Resident R3's centrally stored medication log states the latest medication start date is from April 27, 2022. Facility ADM stated she has not updated the residents R1-R3's centrally stored medication. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2024
Plan of Correction
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ADM stated she will updated the residents Centrally stored medication log. ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will submit the plan of corrections by POC date, June 15, 2024.
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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5