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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707097
Report Date: 02/29/2024
Date Signed: 02/29/2024 05:27:52 PM

Document Has Been Signed on 02/29/2024 05:27 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:PARK AVENUE ADULT RESIDENTIAL FACILITIESFACILITY NUMBER:
430707097
ADMINISTRATOR:EUSTAQUIO,CECILIAFACILITY TYPE:
735
ADDRESS:1992 & 1998 PARK AVENUETELEPHONE:
(408) 241-0605
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 12CENSUS: 10DATE:
02/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Cecilia EustaquioTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator Cecilia Eustaquio

While investigating the complaint dated February 22, 2024, LPA requested to review resident, R1's physicians report. ADM stated she did not have a copy. The ADM stated she sent the case manager. ADM stated the case manager hasn't returned the physician report.

While auditing resident medication records, LPA requested to see R1-R3's centrally stored medication log.
ADM stated she did not have the records at the facility but did have a picture of R1, R2 and R3's centrally stored medication log. ADM stated the Assistant administrator changed the centrally stored medication record, but its in the computer. ADM she doesn't have the current copy of the centrally stored medication record at the facility and the Assistant administrator is out of town.

Deficiencies are being cited during today visit, see LIC809-D. This report was reviewed with ADM Cecilia Eustaquio. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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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Document Has Been Signed on 02/29/2024 05:27 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/29/2024 at 04:50 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: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2024
Section Cited
HSC
80070(b)(8)

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80070 Client Records (b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069
This requirement was not met as evidenced by;
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ADM stated she will write a written plan of action on how the facility has a copy of residents medical assessments. ADM stated she will send a copy of R1's physician's report by POC date, 03/07/2024.
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Based on interview and record review, the facility could not provide a copy of R1's physician's report. ADM stated she gave her copy to the case manger and does not have a copy at the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
03/07/2024
Section Cited
CCR80070(b)(10)

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80070 Client Records (b) Each record must contain information including, but not limited to, the following:(10) Record of current medications, including the name of the prescribing physician, and instructions... of medications. This requirement was not met as evidenced by;
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ADM stated she will write a written plan of action on how the facility will ensure the centrally stored medication log is at the facility and up-to-date with residents medication records. ADM stated she will send LPA a copy of R1-R3's centrally stored medication records by POC date.
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Based on interview and records review, the facility did not have a copy of R1-R3's centrally stored medication records. ADM stated the assistant administrator has that information in his/her computer, but he's out of town. This poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
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