435200608-10-10-2024-26-AS-MTAN-D9WQST-20241010122603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200608
Report Date: 10/10/2024
Date Signed: 10/10/2024 12:26:27 PM

Document Has Been Signed on 10/10/2024 12:26 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:	MAYFLOWER CARE HOME		FACILITY NUMBER:	435200608
ADMINISTRATOR:	ESLAVA, ISABEL M.		FACILITY TYPE:	740
ADDRESS:	668 APACHE COURT		TELEPHONE:	(408) 972-1999
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 6	DATE:	10/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Isabel Eslava		TIME COMPLETED:	12:30 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 Analysts (LPAs) Marcella Tarin, Manuel Monter and Steve Chang conducted an unannounced annual inspection visit, and met with Administrator Isabel Eslava. ADM informed LPAs that the facility has 2 staff and 6 clients. LPAs toured the facility inside and outside which included: kitchen, office area, 6 resident rooms and 3 restrooms. 6 out of 6 resident bedrooms had functioning lights, a chair, clean bedding, dresser and storage space for residents personal belongings. LPAs observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPAs observed the sharps and chemicals storage area locked underneath the kitchen sink. The staff area of the facility was also inspected. The front yard and backyard of the facility was also inspected. While touring the backyard, LPAs observed a trash can and recycling can obstructing the walkway, directly next to room #1. The path the trash can and recycling bin were obstructing are on the emergency evacuation path. (Photograph was taken). LPAs also observed a container of dish soap and fabric softener near the garage door on the side of the home. (Photograph was taken). ADM removed the chemicals and locked them away during visit. LPAs observed two sheds in the backyard that are being used for storage. While touring bathroom #3, LPAs observed a bottle of Oxiclean stain remover in the shower and a Clorox toilet cleaner, near the toilet (Photograph was taken). ADM removed chemicals/cleaning products during visit. While touring hallway next to bedroom #3, LPAs observed Ortho flea & tick killer in hallway linen closet (photograph was taken). ADM removed Ortho flea & tick killer to a locked storage area. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. The hot water temperature in 3 out of 3 hallway resident restrooms was measured at 105.4 and 105 degrees F. Page 1 Out of 2.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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 4

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: MAYFLOWER CARE HOME	FACILITY NUMBER: 435200608
	VISIT DATE: 10/10/2024

NARRATIVE

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The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested. Fire extinguishers were last serviced on 05/08/2024. LPAs observed the facility first aid kit and it was observed to be complete. LPAs requested to review the facility fire drill log. ADM stated she does conducts drills but does not have any documentation.

LPAs reviewed facility records for 3 staff and 3 clients, which were all found to be complete during review.

LPAs reviewed 5 clients medications and centrally stored medication records and found the centrally stored medication records to be complete. LPA interviewed 2 staff.

Deficiencies are being cited during today's visit as per California Code of Regulations Title 22. See LIC809-D This report was reviewed with ADM Isabel Eslava and a copy of the signed report was provided. Appeal Rights were provided.

Page 2 Out of 2. END OF REPORT.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/10/2024 12:26 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: MAYFLOWER CARE HOME	FACILITY NUMBER: 435200608
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview the licensee did not comply with the section cited above. LPAs observed a trash can and a recycling can obstructing the passageway in the backyard outside of bedroom #1. This passageway is part of the emergency evacuation plan which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2024
	Plan of Correction
1 2 3 4	ADM removed the trash and recyling cans during visit. ADM will submit a letter of understanding of the regulation and send to LPA by POC due date.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above. LPAs observed chemicals/detergents accessible to residents in care in bathroom #3, in the passageway outside of the garage exit door, and a hallway linen closet next to bedroom #3. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2024
	Plan of Correction
1 2 3 4	ADM removed chemicals and storage in a locked storage area during visit. ADM states she conduct a training regarding storage of chemicals/detergents and send documenation to LPA. ADM will also submit a letter of understanding of regulation to LPA 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: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/10/2024 12:26 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: MAYFLOWER CARE HOME	FACILITY NUMBER: 435200608
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited. The licensee stated the facility is conduction drills, but the drills are not documented, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2024
	Plan of Correction
1 2 3 4	ADM stated she will conduct a drill and send documentation that a drill has taken place. ADM will also send a statement of understanding of the regulation to LPA by POC due date.

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: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4