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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435200918
Report Date:
05/10/2024
Date Signed:
05/11/2024 12:59:44 PM
Document Has Been Signed on
05/11/2024 12:59 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EVCO CARE
FACILITY NUMBER:
435200918
ADMINISTRATOR:
MICHELLE BAYQUEN
FACILITY TYPE:
740
ADDRESS:
3274 EVCO COURT
TELEPHONE:
(408) 937-1625
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95127
CAPACITY:
6
CENSUS:
3
DATE:
05/10/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
THELMA BLANCHARD
TIME COMPLETED:
01:39 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with licensee Thelma Blanchard (LCN) and Administrator (ADM) Michelle Bayquen.
2 staff and 2 residents were observed in the facility. LCN stated the facility is a RCFE with MI residents.
2 resident file and 3 staff files were reviewed.
LPA toured the facility inside out with ADM. Dinning room, kitchen and family room were inspected. 4 resident bedrooms and 2 restrooms were inspected. 1 office and 1 staff room were observed in the facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet was observed locked. Knives closet, and dish cleaning product closet were observed unlocked. One resident bedroom's screen window was observed missing. Litters were observed on the floors of dining room, kitchen and resident bedrooms. No non-skid mat was observed in the bathrooms. First aid box was observed in the facility. Room temperature was at 70 degree F and hot water temperature was at 119 degree F. Flash lights were observed out of battery. No night light was observed in the hall way, ADM stated the light in the hallway was turned at night. Two residents confirmed the light of the hallway was turned on at night.
Fire extinguisher was serviced on 10/30/2023. The facility was equipped with smoke and carbon monoxide detectors. Carbon monoxide detector was found out of battery. Front yard and backyard were inspected. Three matters were observed at side of the building to block the walkways. LCN stated the last the facility conducted the emergency and fire drill was 4/16/24.
Citations were noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM
SUPERVISOR'S NAME:
Romeo Manzano
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
05/10/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/10/2024
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
9
Document Has Been Signed on
05/11/2024 12:59 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EVCO CARE
FACILITY NUMBER:
435200918
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that carbon monoxide detector was observed out of battery which poses an immediate health, safety risk to persons in care.
POC Due Date:
05/11/2024
Plan of Correction
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2
3
4
ADM stated to submit the plan of correction by the POC due date to install new battery for carbon monoxide detector.
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, the licensee did not comply with the section cited above in that dish washing soap closet was observed unlocked which poses an immediate health, safety risk to persons in care.
POC Due Date:
05/11/2024
Plan of Correction
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2
3
4
ADM stated to submit the plan of correction by the POC due date to lock the dish washing soap closet.
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
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
05/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/10/2024
LIC809
(FAS) - (06/04)
Page:
2
of
9
Document Has Been Signed on
05/11/2024 12:59 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EVCO CARE
FACILITY NUMBER:
435200918
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that knives closet was observed unlock which poses an immediate health, safety risk to persons in care.
POC Due Date:
05/11/2024
Plan of Correction
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2
3
4
ADM stated to submit a plan of correction by the POC due date to lock the knives closet.
Type A
Section Cited
CCR
87468(c)(1)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that personal rights poster were not posted in the common area which poses an immediate personal rights risk to persons in care.
POC Due Date:
05/11/2024
Plan of Correction
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2
3
4
ADM stated to submit a plan of correction by the POC due date to put the personal rights poster on the common area.
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
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
05/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/10/2024
LIC809
(FAS) - (06/04)
Page:
3
of
9
Document Has Been Signed on
05/11/2024 12:59 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EVCO CARE
FACILITY NUMBER:
435200918
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that little were observed on the floor of dining room, kitchen and resident bedrooms which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/17/2024
Plan of Correction
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2
3
4
ADM stated to submit a plan of correction by the POC due date to clean up the facility.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in that one of the resident bedroom's screen window was observed missing which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/17/2024
Plan of Correction
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ADM stated the facility will submit a plan of correction by the POC due date to install a new screen window for the resident bedroom.
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
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
05/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/10/2024
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
05/11/2024 12:59 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EVCO CARE
FACILITY NUMBER:
435200918
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.
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 in that no-skid mats was observed in the bathrooms which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/17/2024
Plan of Correction
1
2
3
4
ADM stated to submit a plan of correction by the POC due date to put the non-skid mats in the bathrooms.
Type B
Section Cited
CCR
87303(h)
Maintenance and Operation
(h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff. Open-flame lights shall not be used.
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 in that the flashlights were observed out of battery which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/17/2024
Plan of Correction
1
2
3
4
ADM stated to submit a plan of correction by the POC due date to install batteries for the flashlights.
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
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
05/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/10/2024
LIC809
(FAS) - (06/04)
Page:
5
of
9
Document Has Been Signed on
05/11/2024 12:59 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EVCO CARE
FACILITY NUMBER:
435200918
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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, the licensee did not comply with the section cited above in that 3 mattress were observed at the side of the building blocking the walkways which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/17/2024
Plan of Correction
1
2
3
4
ADM stated to submit a plan of correction by the POC due date to remove the 3 mattress.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that 3 out 3 staff without first aid certificate which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/17/2024
Plan of Correction
1
2
3
4
ADM stated to submit a plan of correction by the POC due date to have staff obtain first aid training and certificate.
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
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
05/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/10/2024
LIC809
(FAS) - (06/04)
Page:
6
of
9
Document Has Been Signed on
05/11/2024 12:59 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EVCO CARE
FACILITY NUMBER:
435200918
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
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: (11) A health screening as specified in Section 87411, Personnel Requirements - General.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that 3 out of 3 staff were observed no health screening form in the staff files which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/17/2024
Plan of Correction
1
2
3
4
ADM stated to submit a plan of correction by the POC due date to have staff to obtain health screening forms.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that 3 out of 3 staff were observed without annual continuing training document in the staff files which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/17/2024
Plan of Correction
1
2
3
4
ADM stated to have staff obtain and finish the annual continue training.
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
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
05/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/10/2024
LIC809
(FAS) - (06/04)
Page:
7
of
9
Document Has Been Signed on
05/11/2024 12:59 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
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EVCO CARE
FACILITY NUMBER:
435200918
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that 2 out of 2 residents were observed no central stored medications form in the resident files which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/17/2024
Plan of Correction
1
2
3
4
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:
Romeo Manzano
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
05/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/10/2024
LIC809
(FAS) - (06/04)
Page:
8
of
9