435200051-3-13-2025-26-AS-KJAN-DEQQEN-20250313120638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200051
Report Date: 03/13/2025
Date Signed: 03/13/2025 12:07:02 PM

Document Has Been Signed on 03/13/2025 12:07 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:	PARKVIEW RCH #2		FACILITY NUMBER:	435200051
ADMINISTRATOR/ DIRECTOR:	HELEN NG		FACILITY TYPE:	740
ADDRESS:	919 ROSETTE COURT		TELEPHONE:	(408) 736-5618
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94086
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	03/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Lorma Laureta and Helen Ng		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

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On March 13, 2025, at 08:45 AM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Administrator, Elma Pacursa, and disclosed the purpose of the inspection. The Administrator informed the LPA that the facility had (5) residents in care and (3) staff members present at the time. The Licensee, Helen Ng arrived shortly after.

At 9:23 AM, the LPA initiated a walk-through of the facility, accompanied by the Administrator.

LPA inspected the kitchen and found it clean, with no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet containing knives and sharp objects. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted.

LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. (4) residents were observed eating breakfast.

LPA inspected the fire extinguisher mounted on the wall in the kitchen and found it fully charged, with the last service tag dated 06/04/2024. The Administrator tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit.

LPA inspected the living room and observed it clean, with all furniture in good repair. There was a sofa set and a television in the living room. (1) resident was observed watching TV.

Continued on LIC809-C

April Cowan	TELEPHONE: (650) 266-8889
Kiran Jain	TELEPHONE: (650) 416-4836
	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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: 03/13/2025

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There were (6) bedrooms and (2½) bathrooms designated for residents' use. All (6) resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. All exit doors had Auditory alarms for notification. LPA inspected (2½) bathrooms and found them clean, sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip flooring. The hot water temperature at the sink faucet measured 118.7°F in bathroom #1 and 149.8°F in bathroom #2. Bathroom closets were observed to contain clean linens and towels for residents’ use.

LPA inspected the garage and found it clean. A break room for staff with sofa was observed. A washer, a dryer, a refrigerator, a freezer containing additional food supplies, wheelchairs, mattresses, a cabinet with detergents, disinfectants, and cleaning supplies, and storage cabinets with incontinence supplies, and paper products were observed.

LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The backyard has a set of a patio table, chairs, and shaded areas for resident use. No bodies of water and no tripping hazards were noted.

LPA reviewed (5) staff personnel records and (5) resident records. The LPA observed that 4 of 5 residents with dementia did not receive an annual Physician assessment and did not have Appraisal Needs and Services Plan. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility.

LPA observed a locked centrally stored medication cabinet inside the kitchen area. Medications were organized in separate bins for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 01/05/2025.

Continued on LIC809-C

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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: 03/13/2025

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The following updated forms are requested to be submitted to CCLD by 03/20/2025:

LIC 500: Personnel Report
LIC 308: Designation of Facility Responsibility
Certificate of Liability Insurance
Updated Facility Sketch (Floor Plan)
Administrator Certificate(s)

The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted with the Licensee. A copy of this report was left with the Licensee, Helen Ng, whose signature on this form confirms receipt of the report.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/13/2025 12:07 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: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure hot water temperature at the sink faucet for 1 of 2 bathrooms is in the range of 105 - 120 degree F. The hot water temperature was measured at 149.8°F in 1 of 2 bathroom sink faucet, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	The licensee stated that they would fix the high hot water temperature. The license will submit the evidence that hot water temperature is within the range of 105°F - 120°F to CCLD by 03/20/2025.

Type B

Section Cited

CCR

87463(h)

Reappraisals

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not ensure 4 of 5 dementia residents (R1, R3, R4, and R5) received annual physician assessment once every twelve months, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2025
	Plan of Correction
1 2 3 4	The licensee stated that they would get the annual physician assessment done for the four residents. The license will submit the evidence to CCLD by 03/27/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

April Cowan	TELEPHONE: (650) 266-8889
Kiran Jain	TELEPHONE: (650) 416-4836
	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 03/13/2025 12:07 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: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.695(e)(2)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not ensure 4 of 5 residents (R2 - R5) had an appraisal of needs and services plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2025
	Plan of Correction
1 2 3 4	The licensee stated that they would get the appraisal of needs and services plan done for the four residents. The license will submit the evidence to CCLD by 03/27/2025.

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.

April Cowan	TELEPHONE: (650) 266-8889
Kiran Jain	TELEPHONE: (650) 416-4836
	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

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