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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200793
Report Date: 04/28/2023
Date Signed: 05/01/2023 08:01:25 AM

Document Has Been Signed on 05/01/2023 08:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NIKKO'S RESIDENTIAL CARE HOME IIFACILITY NUMBER:
435200793
ADMINISTRATOR:VILLAREAL, MICHELLEFACILITY TYPE:
735
ADDRESS:5724 BLOSSOM AVETELEPHONE:
(408) 972-1792
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 2DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:MIchelle VillarealTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) MIchelle Villareal.

PAs checked 2 resident record files (R1 - R2) and 5 staff record files (S1 - S5). Two staff (S1, S2) were interviewed. Two residents went to day program.

LPAs toured the facility inside out with ADM. Facility license, Administrator Certificate, Personal Rights posters were observed posted at the facility. Living room, family room, kitchen, dinning room and restrooms were inspected. Three resident bedrooms, and laundry room were inspected. Two staff live-in rooms and one storage room are in facility. One of the restroom was changed to be a staff live-in room with restroom which matched with facility sketch floor plan.

Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 110 degree F in facility. Temperature of freezer is 0 degree F, and temperature of refrigerator is 40 degree F.

Fire extinguisher was serviced on 06/29/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways to the exit gate.

Exit interview was conducted with ADM. LIC9099-D, LIC9102 and Appeal Rights were attached. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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 05/01/2023 08:01 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 04/28/2023 at 11:45 AM
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 II
FACILITY NUMBER: 435200793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation, the light of one of the restroom was observed not working, the licensee did not comply with the section cited above, which poses/posed a potential safety risk to persons in care.
POC Due Date: 04/29/2023
Plan of Correction
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Administrator agreed submit the Plan of Correction to fix it by end of today.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility did not have night light in the hall way, the licensee did not comply with the section cited above, which poses/posed a potential safety risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Administrator agreed submit the Plan of Correction to have night light installed at the hall way.
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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/01/2023 08:01 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 04/28/2023 at 11:45 AM
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 II
FACILITY NUMBER: 435200793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, one of the staff (S1) did not have health screening record, the licensee did not comply with the section cited above, which poses/posed a potential health risk to persons in care
POC Due Date: 05/05/2023
Plan of Correction
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Administratro agreed to submit the Plan of Correction by POC due Date to have S1's health screeing record ready.
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 Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
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