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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707097
Report Date: 08/15/2023
Date Signed: 08/15/2023 04:11:44 PM

Document Has Been Signed on 08/15/2023 04:11 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: 12DATE:
08/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Cecilia EustaquioTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings for complaint 26-AS-20201027115321. During visit, violations were observed therefore a case management - deficiencies visit was conducted. LPA met with Administrator (ADM), Cecilia Eustaquio.

During visit, LPA toured the facility with ADM. LPA observed all the fire extinguishers were last serviced in May 27, 2020. ADM shrugged her shoulder and stated to have forgotten to get their fire extinguishers serviced. At the end of the visit, ADM states she has contacted her son, Merv who will schedule an appointment to service the fire extinguishers.

LPA and ADM entered the kitchen area. LPA observed multiple flies in the kitchen and throughout the facility. ADM states she was not sure why there are many flies but states she's trying to exterminate them with a fly swatter and pesticide spray. Upon arrival, LPA observed the front screen door was wide open. LPA observed the facility keeps their front door wide open and observed the front screen door does not completely close shut.

LPA observed accessible laundry detergents and cleaning supplies underneath the kitchen sink. ADM states there's supposed to be a chain to lock the cabinets but it was removed. During visit, staff (S1) installed a lock for the cabinet. LPA walked through the hallway and observed a closet that had cleaning supplies was not locked. ADM immediately locked the closet.

LPA observed a cabinet in the kitchen that contained the ADM's medications were not locked nor did the cabinet contain a lock. The resident's medication cabinet was observed locked. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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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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: 08/15/2023
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LPA entered the dining room area with ADM. LPA and ADM observed 2 medication pills placed inside an open medication cup on the table. ADM stated the medication were for resident (R1) who refused to take their medication. ADM immediately secured the medication.

LPA entered the residents bathroom. Upon entrance, it was observed there were stripped wall paint scattered on the bathroom floor. ADM states they are currently re-painting the bathrooms. LPA observed the toilet was dirty with black and brown dirt spots on the toilet; and the floor surrounding the toilet observed with dark brown spots. LPA observed the shower contained built-up scum marks that was colored white and dark grey. The shower floor also contained a dirty band-aid. ADM and S1 was advised.

LPA entered the next building with ADM. LPA observed cleaning supplies and pesticide spray accessible in the resident's bathroom. A bottle of over the counter medication was also observed accessible inside the bathroom. LPA addressed the issues with ADM, but ADM states for LPA to write it on the report and she will let her son, Mervin know about it.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D.

A civil penalty of $250 will be assessed for a repeat violation within 12 months of the initial citation. If the deficiency is not corrected within 24 hours, an additional $100 will be assessed until the deficiency is corrected. See LIC421FC.

This report was reviewed with Administrator, Cecilia Eustaquio and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/15/2023 04:11 PM - It Cannot Be Edited


Created By: Christine Dolores On 08/15/2023 at 03:07 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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2023
Section Cited
CCR
80087(g)

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(g) Disinfectants, cleaning solutions, poisons, 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:
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Licensee states they will put away the disinfectant Licensee will submit a statement of understanding of section 80087 to LPA Dolores by POC due date.
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Based on interview and observation the licensee did not ensure cleaning solutions and pesticides were locked and inaccessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
08/16/2023
Section Cited
CCR80087(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
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Licensee will submit a written statement of their plan to service the fire extinguishers and to keep up with the cleanliness of the facility to LPA Dolores by POC due date.
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Based on observation and interview the licensee did not ensure the facility's bathroom was kept clean, the kitchen kept free of flies, front door was not in good repair, and fire extinguisher was not annually serviced which poses an immediate health, safety, and 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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/15/2023 04:11 PM - It Cannot Be Edited


Created By: Christine Dolores On 08/15/2023 at 03:20 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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2023
Section Cited
CCR
80075(k)(1)

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(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
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Licensee will submit a written statement of understanding of Section 80075(k)(1) and a plan to ensure medications will be properly secured to LPA Dolores by POC due date.
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Based on interview and observation the licensee did not ensure residents medications were kept in a safe and locked place which poses an immediate health, safety, and 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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


LIC809 (FAS) - (06/04)
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