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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200051
Report Date: 03/05/2024
Date Signed: 03/05/2024 04:25:41 PM


Document Has Been Signed on 03/05/2024 04:25 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:PARKVIEW RCH #2FACILITY NUMBER:
435200051
ADMINISTRATOR:HELEN NGFACILITY TYPE:
740
ADDRESS:919 ROSETTE COURTTELEPHONE:
(408) 736-5618
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:6CENSUS: 6DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Lead staff Elma PacursaTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Lead staff Elma Pacursa, S1. S1 contacted facility ADM and informed her about LPA's visit. ADM arrived shortly after. During the visit, LPA observed 6 residents and 3 staff. ADM informed LPA that she could not stay due to appointment. ADM stated S1 could sign on her behalf.

As LPA approached the entrance of the home, LPA stepped on the wooden planks of the floor, directly next to the front door and two of them were loose and sinked. LPA showed ADM the sinking wooden planks. ADM stated she would remove them and fix it.

As LPA entered the home, Staff S2 introduced him/herself. LPA checked the facility personnel report summary and staff S2 is not associated with the facility. LPA checked guardian and staff S2 is not associated with the facility. LPA reviewed facility LIC500, dated January 17, 2023. The form states S2 is an on call care giver since 2022 and is also a live in. LPA interviewed staff S2. S2 stated he/she is not a full time employee and is a reliever. S2 stated he/she worked today and last week.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 3 restrooms and 6 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. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 110 degrees F in both resident bathrooms.
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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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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: PARKVIEW RCH #2
FACILITY NUMBER: 435200051
VISIT DATE: 03/05/2024
NARRATIVE
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Fire extinguisher was serviced in July 20, 2023. 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 November 10, 2023.

LPA reviewed facility records for 3 staff. LPA reviewed 3 residents records. LPA requested to review weight records for residents R1-R3. S1 stated the facility does not have a weight record for residents. Based on a review of R2's physicians report, dated May 1, 2023, R2 has dementia. LPA reviewed resident R2's Needs and services plan, dated March 4, 2020. S1 stated the facility does not have an updated Needs and services plan for this year.

LPA reviewed 3 resident medications and centrally stored medication records. While reviewing resident R3's medications, LPA observed that R3's centrally stored medication log stated medication #1 had a start date of 9/29/2023. LPA requested Staff S1 to count the medication. Medication #1 had a total of 36 pills. S1 stated she made a mistake and did not update the centrally stored medication log, when she got a new refill. LPA observed medication #2 had a start date of 12/5/2023, based on the centrally stored medication log. LPA requested S1 count the medication. Medication #2 had 25 pills. Further investigation showed that medication #2 had written on the bottom 12/31. S1 stated she made a mistake and did not update the centrally stored medication log with the correct information. LPA conducted interviews with 1 staff (S1) and 2 residents.

Deficiencies cited during today's visit. This report was reviewed with Lead staff Elma Pacursa and a copy of the signed report was provided. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S1 working and residing in the facility without association. Appeal rights were provided.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/05/2024 04:25 PM - It Cannot Be Edited

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: PARKVIEW RCH #2
FACILITY NUMBER: 435200051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review weight records for residents R1-R3. S1 stated the facility does not have a weight record for residents. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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ADM stated she create a weight record log for the residents at the facility. ADM stated she will send a written plan of action on how she will ensure residents weights are observed and recorded to ensure any changes are observed. ADM stated she will send plan of action by POC date, March 12, 2024.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 at the entrance of the home, wooden planks on the floor, directly next to the front door. Two of the wooden planks were loose and sinked when stepped on. ADM stated she would remove them and fix it. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure the facility is in good repair and her plan of action to ensure the wooden planks on the floor do not sink, when stepped on. ADM stated she will send plan of action by POC date, March 12, 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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 03/05/2024 04:25 PM - It Cannot Be Edited

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: PARKVIEW RCH #2
FACILITY NUMBER: 435200051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87355(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above. Staff S2 stated he/she was working at the facility today. While reviewing gaurdian, S2 is not associated to the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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ADM stated she will assoicate S2 to the facility. ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send plan of action by POC date, March 12, 2024.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above. Based on a review of R2's physicians report, dated May 1, 2023, R2 has dementia. LPA reviewed resident R2's Needs and services plan, dated March 4, 2020. S1 stated the facility does not have an updated Needs and services plan for this year. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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ADM stated she will send LPA an updated Needs and services plan for resident S2 by POC date. ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send plan of action by POC date, March 12, 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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/05/2024 04:25 PM - It Cannot Be Edited

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: PARKVIEW RCH #2
FACILITY NUMBER: 435200051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h)(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above. R3's centrally stored medication log stated medication #1 had a start date of 9/29/2023 and medication #2 had a start date of 12/5/23. LPA requested Staff S1 to count the medication. Medication #1 had a total of 36 pills and Medication #2 had 25 pills. S1 stated she made a mistake and did not update the centrally stored medication log with the correct information. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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ADM stated she will conduct a medication training for staff. ADM stated she will send documentaion showing the training has taken place and signitures showing the staff who attended. ADM stated she will send the plan of correction to LPA by POC date, 3/12/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5