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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708454
Report Date: 01/29/2024
Date Signed: 01/29/2024 12:10:42 PM

Document Has Been Signed on 01/29/2024 12:10 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:SARATOGA ADULT CARE CENTERFACILITY NUMBER:
430708454
ADMINISTRATOR:SUSAN HUFFFACILITY TYPE:
775
ADDRESS:19655 ALLENDALE AVENUETELEPHONE:
(408) 868-1262
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY: 30CENSUS: 17DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Operations Manager, Rajvir Kaur TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Operations Manager (OM) Rajvir Kaur. LPA Rai observed 3 staff and 6 clients at the facility.

During visit, LPA Rai toured the inside and outside of the facility. LPA Rai toured the facility kitchen and observed required food supply of perishable food and nonperishable food. The facility is delivered fresh food by a catering company and prepared by volunteers for lunch service.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.1F - 105.4F. The water temperature in the kitchen sink was 108.9F.

Fire extinguisher was observed and inspected on 03/13/2023. Facility smoke detectors and carbon monoxide detectors were last inspected on 3/3/2023. The last disaster drill was conducted on 10/19/2023.

LPA Rai reviewed facility records for 3 staff and 5 clients. LPA Rai reviewed R2's client file did not contain an Appraisal/Needs and Services Plan. OM stated the client did not have a Care Plan on file and they will work on creating a Care Plan for R2. LPA Rai reviewed 3 out of 3 staff file did not contain Health Screening Report. OM stated the facility will schedule for facility staff to complete a health screening report.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Operations Manager, Rajvir Kaur. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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 01/29/2024 12:10 PM - It Cannot Be Edited


Created By: Simranjit Rai On 01/29/2024 at 11:44 AM
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: SARATOGA ADULT CARE CENTER
FACILITY NUMBER: 430708454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(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 82065(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 in 3 out of 3 staff files did not complete a health screening report, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Operations Manager stated she will submit a plan of action of when the staff will complete the health screening and understanding the regulation by POC due date. Operations Manager agreed and understood.
Type B
Section Cited
CCR
82068.2(f)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include:

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 in 1 out of 3 client files did not contain a Care Plan/ Needs and Services Plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Operations Manager stated she will submit a plan of action of when the resident will have a completed Care Plan and understanding the regulation by POC due date. Operations Manager agreed and understood.
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: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
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