430707097-1-27-2023-26-AS-SRAI-CNGVW7-20230127154729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430707097
Report Date: 01/27/2023
Date Signed: 01/27/2023 03:47:41 PM

Document Has Been Signed on 01/27/2023 03:47 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 FACILITIES		FACILITY NUMBER:	430707097
ADMINISTRATOR:	EUSTAQUIO,CECILIA		FACILITY TYPE:	735
ADDRESS:	1992 & 1998 PARK AVENUE		TELEPHONE:	(408) 241-0605
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY: 12		CENSUS: 11	DATE:	01/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Cecilia Eustaquio.		TIME COMPLETED:	03:55 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	Licensing Program Analyst (LPA) Simi Rai and LPA Manuel Monter conducted an unannounced annual inspection focusing on infection control. LPAs met with Administrator Cecilia Eustaquio. Upon entering the facility, LPAs observed ADM cooking dinner in the kitchen and staff S1 stated S1 was cleaning the bathroom next to the kitchen. During the tour of the facility with S1, LPAs observed bottles of cleaning solution in entrance to the kitchen, recreation room, 2 bathrooms, 1 living room, kitchen, and outdoor area, where residents were also around. LPAs also observed 2 new cans of insecticides at the doorway entering the kitchen. S1 removed the items in question and locked them away in front of LPAs. S1 acknowledged these items should be locked but did not have a reason why they were kept in common areas, which were easily accessible to residents. Based on review of facility file, facility has been cited in the past regarding failure to ensure poisons were locked and inaccessible to the residents in 2019, 2014 and 2013. Based on resident records and observations, the facility cares for residents who need care and supervision. LPAs toured the facility to include 4 bathrooms, 6 bedrooms, 2 living rooms, 2 kitchens, recreation room, and exterior. All fire exit routes are free and clear of obstruction. Toxins and sharp objects were secured. Medication stored in a locked room. Facility observed to have a designated central entry point but did not include a sign-in sheet and temperature check. Facility clean as often as needed. Bathrooms supplied with hygiene products and hand washing signs was observed in 2 out of 4 bathrooms. Trash can with lid was not observed and S1 stated the trash bins will be replaced.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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 01/27/2023 03:47 PM - It Cannot Be Edited

Created By: Simranjit Rai On 01/27/2023 at 03:02 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: 01/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Builidngs and Grounds (g) Disinfectants, cleaning solutions, posions, firearms, and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee/administrator did not comply with the section cited above to ensure poisions were locked and inaccessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/28/2023
	Plan of Correction
1 2 3 4	Administrator corrected deficiency during inspection. LPAs observed S1 and Administrator removing the insecticide and cleaning products in a locked cabinet. Administrator will train staff and provide training logs. Administrator will provide a letter understanding Title 22 regulations specifically storing toxic chemicals along with a written plan of correction.

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:

Simranjit Rai

LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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: PARK AVENUE ADULT RESIDENTIAL FACILITIES	FACILITY NUMBER: 430707097
	VISIT DATE: 01/27/2023

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LPAs did not observed a sufficient amount of Personal Protective Equipment (PPE). ADM stated she will arrange for additional PPE supplies. Staff are not N95 fit tested. The following posters observed to include wash your hands, symptoms of COVID-19, and importance of wearing a mask.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure correct the deficiencies may result in civil penalties. Technical Advisory notes was provided.

This report was reviewed with Administrator Cecilia Eustaquio, and a copy of the report was provided. Appeal Rights were provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC809 (FAS) - (06/04)

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