435200733-10-27-2024-26-AS-MPAA-DAFRNL-20241027131031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200733
Report Date: 10/27/2024
Date Signed: 10/27/2024 01:10:54 PM

Document Has Been Signed on 10/27/2024 01:10 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:	NIKKO'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	435200733
ADMINISTRATOR/ DIRECTOR:	SEDIGH, MALOU		FACILITY TYPE:	735
ADDRESS:	13540 COLUMBET AVE		TELEPHONE:	(408) 683-4354
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY: 6		CENSUS: 5	DATE:	10/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Jhanelle Guico - Designated Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:15 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 Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required 1 year inspection visit and met with designated administrator (DADM) Jhanelle Guico and stated the purpose of the visit. Administrator Malou Sedigh, was not present at the time of the visit. DADM stated that ADM was not available due to prior commitment. The facility is licensed to serve adults 18 to 59 all may be non-ambulatory and developmentally disabled. LPA observed 4 Out of 5 residents (R1 to R5) and 4 staff were present at the facility. 1 Out of 5 resident was inside the room with 1 staff, 2 out of 5 was watching TV with 1 staff, 2 out of 5 was with 1 staff outside playing catch ball. 1 Out of 5 is with family. At 9:00 a.m. LPA toured the facility inside and outside with DADM including but not limited to the kitchen, bathroom, dining room, living room, 5 residents rooms, garage, backyard and exterior perimeter. The temperature inside the home was at 72 degrees Fahrenheit. The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. The kitchen water temperature measured at 112.6 degrees Fahrenheit. LPA observed the drawers in the dining room was not closing properly, the cabinet kitchen door left side of the stove came off the hinge. The bathroom are equipped with grab bars and non-skid mats. The water temperature in the bathroom measured at 112.4 degrees Fahrenheit. Resident's room have sufficient storage. LPA observed Room 5 has a broken armoire the drawers cannot be easily opened. Each room has emergency exit doors that access the backyard. LPA observed an alarm for each door that requires the batteries to be replaced. DADM stated that the facility has a night staff that watches over the residents. page 1 of 2, see LIC 809C

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2024

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 3

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: NIKKO'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 435200733
	VISIT DATE: 10/27/2024

NARRATIVE

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LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete and is accessible to staff.

The facility screen windows were observed to be in good repair. The washer and dryer located in the garage and are in good working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care. The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition, night lights on the hallway are in good working condition. The hallway are free from obstruction.

The exterior walkways and ramp are free from debris and obstruction. LPA observed the backyard has uneven pavement, the metal trash bin was overflowing, some of the trash was laying on the ground. LPA observed 4 inoperable vehicles stored at the exterior, a broken shed, an open ditch approximately 2 ft deep x 6 ft long x 2 feet wide. There were piles of dry woods, old furniture covered with tarp at the side of the building. Overgrown grass and dry bushes by the fence at left side of the property. An electrical cord was running through the ground used for the air fryer and the electric stove outside placed under the tree. There were play equipment such as swing and slide that were no longer in use.

LPA reviewed 3 out of 5 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed records to be current and updated .

LPA reviewed 3 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. All staff have criminal record clearance/fingerprints and records were updated. The facility's Fire extinguisher was last inspected on 6/12/2024. The fire drill was administered on 10/13/24 and earthquake was drill was administered 8/10/24.

Deficiencies were cited during today's vist based on California Code of Regulation (CCR) Title 22,
See LIC809D. An exit interview was conducted with DADM Jhanelle Guico. A copy of the report and appeals rights were provided.

page 2 of 2
end of report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/27/2024 01:10 PM - It Cannot Be Edited

Created By: Maria Partoza On 10/27/2024 at 12:29 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: NIKKO'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 435200733
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not keeping the grounds safe and in good repair at all times. LPA observed uneven pavement, open ditch approximately 2 ft deep x 6 ft long x 2 feet wide, a running electrical cord, dry woods, inoperable vehicles, broken shed, broken drawers and cabinet doors, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2024
	Plan of Correction
1 2 3 4	DADM stated that the deficiney with the grounds will be addressed with the licensee. DADM will submit a written plan of correction by the due date on how the facility will maintain the exterior grounds to ensure that residents are not exposed to any hazardous materials and unsafe environment.

Type A

Section Cited

CCR

80088(f)

Fixtures, Furniture, Equipment, and Supplies

(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not ensuring that solid waste are disposed properly. LPA observed the metal trash bin was full capacity, lid cannot be closed properly and trash was laying on the ground that could pose as a food source for insects and rodents that transmit communicable disease, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2024
	Plan of Correction
1 2 3 4	DADM stated that the trash are scheduled for pick up Tuesdays of each week but trash was not picked up the week before. DADM will submit a written plan of correction by due date on how the facility will ensure that solid wastes are disposed properly to ensure the residents are safe from communicable disease.

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:

Maria Partoza

LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2024

LIC809 (FAS) - (06/04)

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