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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707868
Report Date: 12/27/2024
Date Signed: 12/27/2024 06:07:21 PM

Document Has Been Signed on 12/27/2024 06:07 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:FLORENCE RESIDENTIAL CARE HOME #2FACILITY NUMBER:
430707868
ADMINISTRATOR/
DIRECTOR:		PERLA DIMALANTA ZEIJNALIFACILITY TYPE:
735
ADDRESS:135 NORTH 8TH STREETTELEPHONE:
(408) 293-0362
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 10CENSUS: 9DATE:
12/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Staff S1, Winnie RodriguezTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff S1, Winnie Rodriguez. During the visit, LPA observed 9 residents and 1 staff. LPA explained the purpose of the visit.

Staff S1 contacted ADM via phone call. ADM stated she would not be able to meet LPA at facility because she is working. LPA asked ADM how many hours she spends at the facility a week. ADM stated she spends 6-7 hours at the facility each week.

LPA toured both homes, 129 and 135, inside out with S1 which included the Living room, kitchen, dining room, 3 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. Room temperature was at 72 degrees F, and hot water temperature was measured at 108 degrees F in resident bathrooms.

While touring bath #1, LPA observed a container of bleach on the floor. LPA also observed dirt and grime on the side of the sink. (Photograph was taken.) LPA also observed the mirror above the sink had stains. LPA also observed the kitchen sink, toilet and shower had stains. LPA observed the shower in bath #1 had an opening. (Photographs were taken.)

While touring resident bedroom #2, LPA observed two holes exposing the inside of the wall, near a residents bed. (Photograph was taken.).

Page 1 Out of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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 8
Document Has Been Signed on 12/27/2024 06:07 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/27/2024 at 05:20 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: FLORENCE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 430707868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed several instances where cleaning materials such as ajax were acsessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger to residents, are inacessible to residnets in care. ADM stated she will send the Plan of correction by POC date, 12/28/2024.
Type A
Section Cited
CCR
80064(a)(3)
Administrator Qualifications and Duties
(3) Knowledge of and ability to comply with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on culmination of todays visit and the defficencies that are being cited today, the licensee did not comply with the section cited above. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2024
Plan of Correction
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ADM stated she will send a letter of understanding regarding her role and responsiblity as the administrator and how she will ensure she has the Knowledge of and ability to comply with applicable law and regulation. ADM stated she will send the Plan of correction by POC date, 12/28/2024.
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: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 12/27/2024 06:07 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/27/2024 at 05:20 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: FLORENCE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 430707868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Except for children's residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. S1 admitted that he/she locks the kitchen door, denying residents acsess to the fridge. Residents do not have acsess to the facility's refrigerator. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure residents have acess to the facility kitchen, including the fridge. ADM stated she will send the written plan of action and send to LPA by POC date, 12/28/2024.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. While touring resident bedroom #5, LPA observed a bottle of Dayquil severe cold & flu on top of resident's dresser. LPA observed residents medications in the kitchen sink, unlocked. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure Medication shall be kept in a safe and locked place that is not accessible to residents in care. ADM stated she will send this written plan of action to LPA by POC date, 12/28/2024.
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: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 12/27/2024 06:07 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/27/2024 at 05:20 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: FLORENCE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 430707868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(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:
Deficient Practice Statement
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Based on the noted observations throughout the 809 and 809-C, the licensee did not comply with the section cited above. LPA noted mulitple areas of the facility that were not clean/sanitary, including the bathrooms, backyard, residents bedsheets and kitchen. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure The facility shall be clean, safe, sanitary and in good repair at all times. ADM stated her written plan of action will address the noted areas on the 809 and 809-C. ADM stated she will send the written plan of action by POC date, 01/03/2025.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. LPA requested to review S1's health screening. S1 stated he/she did not complete it. LPA requested to review S2's health screening. S2 stated he/she did complete it but cannot not give LPA copy to review. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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ADM stated staff S1 and S2 will complete a health screening. ADM stated she will send LPA a copy of the completed health screening and send to LPA by POC date, 01/03/2025.
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: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 12/27/2024 06:07 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/27/2024 at 05:20 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: FLORENCE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 430707868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. LPA requested to review Staff S1's training. S1 stated he/she trained in Oregon. S1 stated he/she only has training in first aide. LPA requested to review Staff S2's training documents. S1 was unable to provide documentation showing S2's training. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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ADM stated she will send documenation showing staff S1 and S2 have completed their on the job training. ADM stated she will send LPA documenation the training has been completed by POC date, 01/03/2025.
Type B
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a layer of grease on the kitchen stove and alongside the walls and ceiling. LPA observed dirt and grime along the refrigerator. LPA observed a cockroach in the kitchen. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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ADM stated she will send a written plan of aciton on how she will ensure All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin. ADM stated she will send the written plan of action by POC date, 01/03/2025.
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: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 12/27/2024 06:07 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/27/2024 at 05:20 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: FLORENCE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 430707868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA requested to review R3's needs and services plan. S1 was unable to provide LPA with a copy. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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ADM stated she will send LPA with a copy of R3's Apprisal/Needs and Services Plan. ADM stated she will send to LPA by POC date, 01/03/2025.
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Resident R1-R3's medications that were filled in December 2024 were not listed in the centrally stored medication log. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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ADM stated she will send LPA an updated copy of resident R1-R3's centrally stored medication log, which will include the medications that were filled in December 2024. ADM stated she will send to LPA by POC date, 01/03/2025.
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: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


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Page: 6 of 8
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: FLORENCE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 430707868
VISIT DATE: 12/27/2024
NARRATIVE
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During tour, LPA observed staff S1 unlock the kitchen door. S1 stated the kitchen door remains locked because of the residents condition and the medicines and knives are located in the kitchen. LPA observed a layer of grease on the kitchen stove and alongside the walls and ceiling. (Photographs were taken.) LPA also observed a cockroach in the kitchen floor. (Photograph was taken.). LPA observed knives in the kitchen that were not locked. LPA observed resident medication cabinet that did not have a locking mechanism. (Photographs were taken.). LPA the inside of the facility fridge had stains. LPA also observed duct tape being used inside the fridge, and broken container inside. (Photographs were taken.) While touring the dinning room, LPA observed a freezer with an assortment of frozen food and a smaller black fridge with an assortment of condiments. S1 stated residents cannot access the larger refrigerator. S1 stated the residents are not allowed.

While touring bath #2, LPA observed underneath the kitchen sink dirt and grime. A containers of cleaning containers were observed. (Photograph was taken.) LPA also observed the shower walls had stains. (Photographs were taken.)

While touring the backyard, LPA observed a container of bleach and fabric softener. LPA also observed several car batteries laid across various locations in the backyard. LPA also observed an accumulation of leaves, branches in the backyard (including leafage from the palm tree.) LPA also observed several containers of gasoline and motor oil in several locations in the backyard. (Photographs were taken.)

While touring resident bedroom #4, LPA observed a cabinet that was missing its door. (Photograph was taken.)

While touring bath #3, LPA observed an assortment of cleaning products, such as ajax, on the floor. (Photograph was taken.)


Page 2 Out of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
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Page: 7 of 8
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: FLORENCE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 430707868
VISIT DATE: 12/27/2024
NARRATIVE
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While touring resident bedroom #5, LPA observed in indentation on the dry wall, across from a residents bed. (Photograph was taken.) LPA observed residents sheets with stains and an odor was noted from the sheets. (Photograph was taken.) LPA observed a bottle of Dayquil severe cold & flu on top of resident's dresser. (Photograph was taken.)

Fire extinguisher was serviced in October 3, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 4, 2024.

LPA reviewed facility records for 3 staff. LPA requested to review Staff S1's training. S1 stated he/she trained in Oregon. S1 stated he/she only has training in first aide. LPA requested to review Staff S2's training documents. S1 was unable to provide documentation showing S2's training. LPA requested to review S1's health screening. S1 stated he/she did not complete it. LPA requested to review S2's health screening. S2 stated he/she did complete it but cannot not give LPA copy to review.

LPA reviewed 3 resident records. LPA requested to review R3's needs and services plan. S1 was unable to provide LPA with a copy.

LPA reviewed 3 resident medications and centrally stored medication records. Resident R1-R3's medications that were filled in December 2024 were not listed in the centrally stored medication log. (Photographs were taken.)

Deficiencies are cited during today's visit. This report was reviewed with Staff S1, Winnie Rodriguez and a copy of the signed report was provided. Appeal Rights were provided.

Page 3 Out of 3. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
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