430707808-5-25-2023-26-AS-CDOS-CS6W4M-20230525165747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430707808
Report Date: 05/25/2023
Date Signed: 05/25/2023 04:57:55 PM

Document Has Been Signed on 05/25/2023 04:57 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:	HOPE REHABILITATION SERVICES - PARKMOOR		FACILITY NUMBER:	430707808
ADMINISTRATOR:	JUAN GUEL		FACILITY TYPE:	775
ADDRESS:	1555 PARKMOOR AVENUE		TELEPHONE:	(408) 282-0449
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY: 60		CENSUS: 20	DATE:	05/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Nga Au		TIME COMPLETED:	05:05 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) Christine Dolores arrived unannounced to conduct the facility's annual inspection. LPA met with Manager, Nga Au. During visit, LPA toured the day program with Manager to include the offices, activity room, and kitchen area. LPA observed the clients participating in two different group activities. Facility temperature maintained at 72 degrees Fahrenheit. Sharp objects, disinfectants, and chemicals observed locked in the kitchen cabinet. Kitchen has an operable carbon monoxide detector. LPA did not have a working thermometer to measure the hot water temperature. Manager was advised the hot water temperature should not exceed 120 degrees Fahrenheit. Manager stated understanding. LPA observed the activity room is supplied with various activities to provide for clients. Exits and passageways were free and clear of obstruction. LPA reviewed 4 clients (C1 - C4) files contained emergency information, physician's report, TB results, needs and services plan, consent forms, and personal rights form. 1 out of 4 residents needs and services plan was last updated in 2019. Manager was advised. LPA did not observe 3 out of 4 residents files contained an admission agreement. Facility was advised. LPA interviewed C1 - C4. LPA interviewed 3 staff (S1 - S3) members. LPA reviewed 3 staff members files contained an update 1st Aid Certification and at least 8 hours of training. The facility did not have a health screening report physically present for review. Manager states the records are located in another office but was unable to get a hold of a personnel to show the record. Manager verbally states all staff have received a test for TB and will forward the information to LPA Dolores by 05/26/2023. Facility was advised to ensure all personnel records to be present on site. Facility last conducted an emergency drill on 05/23/2023. SEE LIC809-C.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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 05/25/2023 04:57 PM - It Cannot Be Edited

Created By: Christine Dolores On 05/25/2023 at 03:52 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: HOPE REHABILITATION SERVICES - PARKMOOR	FACILITY NUMBER: 430707808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82066(d)

Personnel Records

(d) All personnel records shall be maintained at the program site. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the facility does not maintain a physical copy of staff members health screening report to include their TB information which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/01/2023
	Plan of Correction
1 2 3 4	Licensee will send LPA Dolores their written plan to ensure all personnel records will be maintained at the program site. Licensee will submit the POC via email to LPA Dolores by POC due date.

Type B

Section Cited

CCR

82068(a)

Admission Agreements

(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the facility did not maintain a complete admission agreement for 3 out of 4 client files reviewed by the LPA which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/01/2023
	Plan of Correction
1 2 3 4	Licensee will audit all client's files to observe if they have an admission agreement. Licensee will submit their written plan to ensure all clents will have a complete admission agreement on file to LPA Dolores via email by POC due date.

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: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 05/25/2023 04:57 PM - It Cannot Be Edited

Created By: Christine Dolores On 05/25/2023 at 04:01 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: HOPE REHABILITATION SERVICES - PARKMOOR	FACILITY NUMBER: 430707808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

82019(e)(1)

(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (1) Obtain a California clearance or a criminal record exemption as required by the Department; or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review staff (S3 - S5) did not obtain a criminal record clearance by the Department which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/26/2023
	Plan of Correction
1 2 3 4	S3 - S5 will not work in the facility until they have obtained a criminal record clearance by the Department. Licensee will send S3 - S5 for a criminal record clearance, ASAP. Licensee will submit a statement of understanding of section 82019 to LPA Dolores via email by POC due date. Licensee was provided 82019.

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:

Sarah Yip

LICENSING EVALUATOR NAME:

Christine Dolores

LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: HOPE REHABILITATION SERVICES - PARKMOOR	FACILITY NUMBER: 430707808
	VISIT DATE: 05/25/2023

NARRATIVE

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Posters observed to include personal rights, if you see something say something, grievance, facility sketch for emergency evacuation, and COVID related posters.

LPA observed staff (S3, S4 and S5) were not fingerprint cleared by the Department. The facility provided documentation showing S3 - S5 were provided a background check through a third party company. Manager was informed that S3 - S5 cannot work in the facility until they have obtained a criminal record clearance from our Department. Manager was provided information regarding the Department's background check system called Guardian and provided the LIC9183.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $1,500 ($100 per day x 5 days x 3 staff = $1,500), for staff (S3 - S5) working at the facility without fingerprint clearance from the Department. Please see LIC 421BG.

This report was reviewed with Manager, Nga Au and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

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