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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200791
Report Date: 04/28/2024
Date Signed: 04/28/2024 03:28:45 PM


Document Has Been Signed on 04/28/2024 03:28 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:CONSTANTIN'S CARE HOMEFACILITY NUMBER:
435200791
ADMINISTRATOR:LAPUSTEA, CONSTANTINFACILITY TYPE:
740
ADDRESS:5836 ETTERSBERG DRIVETELEPHONE:
(408) 229-0365
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 6DATE:
04/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Constantine LapusteaTIME COMPLETED:
03:00 PM
NARRATIVE
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On 4/28/2024, Licensing Program Analysts (LPA) Maria (Mita) Partoza and Simi Rai conducted an unannounced visit to the facility. LPA stated that the purpose of the visit is to continue the case management-deficiencies observed from 4/27/2024, and to deliver the deficiency citations based on observation and interview from 4/27/2024. LPAs were met by a care giver (S2) and S2 called the licensee/administrator (LIC/ADM) Constantin Lapustea and LIC/ADM arrived at the facility within 30 minutes. LIC/ADM stated he was attending church.

On 4/27/2024 LPA Partoza conducted an unannounced complaint visit to the facility and was greeted by the staff's (S1) child who is a minor (M1). LPA was able to confirm that M1 is under the age of 18. LPA arrived at 9:00 a.m. on 4/27/2024 and requested to see LIC/ADM or the designated administrator. M1 stated that the licensee/administrator (LIC/ADM) Constantin Lapustea and caregiver (S2) was out. M1 stated he/she is the child of the staff (S1) who is currently accompanying and assisting 3 residents with their walk and will be back in 15 minutes. LPA observed that M1 was alone with 2 residents for more than 15 minutes with 2 out of 2 residents that are diagnosed with dementia and are ambulatory.

During visit on 4/27/2024, LPA observed the following: 3 residents with the staff (S1) came in after their walk around the neighborhood. LPA observed that 2 out of 3 residents uses assistive device such as cane and walker. 1 out of 3 uses assistive device as needed (walker). S1 introduced self and stated that he/she is the caregiver at the facility and LIC/ADM are not in the facility during the time of visit of 4/27/2024. LPA conducted a facility inspection and observed that 5 out 6 residents were present in the facility. 1 out of 6 went out to a day program.

continued to page 2 - LIC 809C
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2024
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 5


Document Has Been Signed on 04/28/2024 03:28 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: CONSTANTIN'S CARE HOME
FACILITY NUMBER: 435200791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2024
Section Cited
CCR
87355(e)(1)

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87355 All individuals...pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by
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Licensee/ADM stated that all staff prior to working at the facility have criminal background and fingerprint clearance prior to working at the facility. Licensee will have staff fingerprinted and ensure that residents are protected from any harm.
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Based on interview Licensee/ADM stated that he hired a staff that does not have a fingerprint or criminal background clearance prior to working at the facility, which pose/poses an immediate health, safety and personal rights risk to residents in care.
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Licensee/ADM will provide a written plan of action by POC due date. LIC/ADM agreed and understood.
Type A
04/29/2024
Section Cited
CCR87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in privately owned facilities (a)(4)To care, supervision...that meet their..needs and are delivered by staff that are sufficient in qualifications...This requirement is not met as evidenced by:
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Licensee/ADM stated that staff will have sufficient qualification to provide care & supervision that meets the needs of the persons in care, by providing training and guidance to staff. Licensee/ADM will provide a written plan of action by POC due date. LIC/ADM agreed and understood.
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Based on interview and observation, Licensee/ADM did not provide care & supervision to residents by leaving the resident unattended and with a person who is a minor, which pose/poses an immediate health, safety and personal rights risk to persons in care.
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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: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 04/28/2024 03:28 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: CONSTANTIN'S CARE HOME
FACILITY NUMBER: 435200791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2024
Section Cited
CCR
87705(f)

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87705 Care of Person with dementia. (f) The following shall be stored inaccessible to residents with dementia: (1) Knives...(2)Over-the counter medication... supplements...
toxics... such as... cleaning supplies...This requirement was not met as evidenced by:
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Licensee/ADM stated to ensure that cleaning supplies and knives are locked at all times to ensure the safety of persons in care. Licensee/ADM will submit a written plan of action by the POC due date. Licensee/ADM agreed and understood.
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Based on observation, Licensee/ADM did not ensure that toxics, medications & knives located in the kitchen and three bathroom sink cabinets are inaccessible to persons with dementia, which pose/poses an immediate health, safety and personal right risk to persons in care.
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Type A
04/29/2024
Section Cited
CCR87465(h)(2)

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87465 Incidental Medical and Dental Care Services (h)(2) Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication. This requirement is not met as evidenced by:
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Licensee/ADM stated that prescription and over-the counter medications is not accessible to persons in care. Licensee/ADM will submit a written plan of action by the POC due date. Licensee/ADM agreed and understood.
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Based on observation Licensee/ADM did not lock the upper kitchen cabinet and resident's prescription medication were accessible, which pose/poses an immediate health, safety and personal risks to persons in care.
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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: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/28/2024 03:28 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: CONSTANTIN'S CARE HOME
FACILITY NUMBER: 435200791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2024
Section Cited
CCR
87405(d)(1)*

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87405 Administrator - Qualifications and Duties (d)The administrator shall have the qualifications specified in Sections 87405(d) (1) through (7) If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by:
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LIcensee/ADM stated that a letter of understanding regarding Title 22 regulation by POC due date. Licensee/ADM agreed and undestood.
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Based on observation, interview & record review, Licensee/ADM did not provide, care and supervision, did not ensure knives,toxics and medication are inaccessible to residents with dementia, and did not ensure staff has obtained a California criminal record clearance before providing direct care
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to residents, which pose/poses an immediate health, safety and personal risks to persons in care.

*87405(d)(1-7)

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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: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


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: CONSTANTIN'S CARE HOME
FACILITY NUMBER: 435200791
VISIT DATE: 04/28/2024
NARRATIVE
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During the visit of 4/27/2024, LPA interviewed S1. S1 stated that he/she is not fingerprinted and not background cleared. S1 stated that he/she has been working at the facility since September 2023 and works at the facility every other weekends. LPA observed that S1 is not associated and listed on the facility roster and on the department's record under the facility personnel summary report. S1 stated that he/she does not have criminal background clearance and have not completed livescan for fingerprint clearance.

During today's visit, LPAs interviewed LIC/ADM. LIC/ADM admitted that he did not have S1 fingerprinted and have a criminal background clearance prior to working in the facility.

On 4/27/2024, LPA toured the facility and checked bathroom, kitchen and residents' room and observed that the drawer for knives were unlocked and key was located in the key hole. The cabinet under the sink has chemicals and the cabinet was unlocked. LPA observed that the medications for the day in the upper kitchen cabinet, such as Nyquil, Robitussin, Centrum, Magnesium and resident's prescription medications were unlocked and easily accessible to residents in care. The medication was also accessible to staff who is not responsible to administer and supervise medication to residents in care. LPA inspected the bathrooms and 3 out of 3 bathroom sink cabinets was unlocked and contains chemicals, such as Lysol cleaning solutions, bar counter cleaner, were easily accessible to residents in care. LPA reviewed records for 2 out of 2 residents were diagnosed with dementia and are ambulatory. During today's visit, LPAs observed 3 out of 6 resident walking around the facility.

Deficiencies is being cited during today's visit based on California Code of Regulation, Title 22, please see LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days) for staff (S1) working at the facility without fingerprint clearance. See LIC 421BG.

An exit interview was conducted with LIC/ADM Constantin Lapustea and a copy of the report was provided. Appeal rights was also provided.

End of Report
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5