430706162-8-15-2024-26-AS-MPAA-D86QSU-20240815122607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430706162
Report Date: 08/15/2024
Date Signed: 08/15/2024 12:26:18 PM

Document Has Been Signed on 08/15/2024 12:26 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:	AMOR RESIDENTIAL CARE HOME		FACILITY NUMBER:	430706162
ADMINISTRATOR:	VALIN, AMOR & VIRGIL		FACILITY TYPE:	740
ADDRESS:	32 NORTH 21ST STREET		TELEPHONE:	(408) 971-4244
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY:	24	CENSUS: 17	DATE:	08/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Lourdes Basconcillo Designated Administrator		TIME COMPLETED:	12:30 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	On 8/15/2024, at 8:45 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Required - 1 Year visit and met with Lourdes Bansoncillo lead staff (LS) for the facility. LS called the administrator Amor and Valin Virgil. ADMs stated that they out of town due to family emergency and have authorized LS to sign for the report. The facility services adults 60 years and over capacity of 24 of which 20 may be non-ambulatory. The facility has a current census of 17 residents who are ambulatory. At 9:00 a.m. LPA reviewed facility record, 5 of 17 resident record including their Centrally Stored Medication and Destruction record, 4 of 4 facility staff record and found all records to be complete and updated. The fire and earthquake drill are up to date. At 10:45 a.m. LPA toured the facility inside and outside, including 2 kitchen and 1 common dining area. The facility has four buildings #32, #34, #36 & #38. LPA observed no sharps, knives or toxic under the sinks, shelves and cabinets. LPA observed building maintenance is ongoing. LPA observed resident of which 5 of 17 are in their bedroom resting, 2 of 17 are in the common living room, 4 of 17 are watching TV at the covered porch 1 of 17 seated at the gazebo, and 2 of 17 by the courtyard seated and resting. LPA observed food supplies are stored in as separate area/building and shed. LPA observed 2 days of perishable and 7 days of non-perishable food, to LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. See 809-C for more information. Page 1 of 2

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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

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: AMOR RESIDENTIAL CARE HOME	FACILITY NUMBER: 430706162
	VISIT DATE: 08/15/2024

NARRATIVE

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LPA observe 7 fire extinguishers with service tags dated on 8/8/2023. LPA observed smoked, and carbon monoxide detectors that are functioning properly when tested.

LPA observed resident bedrooms and observed each room to have functioning lights, drawers and smoke detectors. LPA observed the drawers to be free of sharps or unsecured medications and each bed to have sheets, blankets, and bed covers. LPA observed that all residents bedrooms have sufficient storage space for personal belongings and are kept sanitary and organized.

LPA observed walkways and hallways to be free from obstructions, the courtyard is free from debris and kept maintained. The common living area was kept organized and sanitary.

LPA observed four resident bathrooms and observed each bathroom to have functioning lights and showers with grab bars. The bathroom water temperatures measured from 97.7 degree F to 105 degree F. LPA observed that bathroom at building #38 located on the hallway has standing water in the shower area and along the toilet seat. Building #32 does not have any resident. LPA observed the shower curtain lining of the bathroom at bldg #32 is frayed/ripped at the bottom and stained with soap & water residue and observed that the sink has a counter marble block back splash that peeled off from the wall (photos were taken).

LPA discussed with lead staff and administrator via a telephone call regarding housekeeping such as but not limited to changing shower liners, and ensuring bathrooms have no standing water and water temperature measures at 105 degree F to 120 degree F. LPA gave technical advisory.

LPA requested a copy of the following: LIC 500, LIC 308, Liability Insurance, Administrator Certificate and resident roster.

No deficiency was issued during today's visit based on California Code of Regulation and a copy of the report was provided. An exit interview was conducted with lead staff Lourdes Basconcillo.

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end of report

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2