435201229-3-30-2023-26-AS-SRAI-CQEUCW-20230330152838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201229
Report Date: 03/30/2023
Date Signed: 03/30/2023 03:32:00 PM

Document Has Been Signed on 03/30/2023 03:32 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:	LOVELY CARE HOME		FACILITY NUMBER:	435201229
ADMINISTRATOR:	ELIZA DAQUIOAG		FACILITY TYPE:	740
ADDRESS:	3640 HEATHCOT COURT		TELEPHONE:	(408) 531-9515
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY:	6	CENSUS: 5	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Licensee Eliza Daquioag		TIME 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 Analysts (LPAs) Simi Rai and Manuel Monter conducted an unannounced Required 1 Year visit and met with Licensee Eliza Daquioag. During visit, LPAs toured the inside and outside of the facility. LPAs toured the facility kitchen and observed food supply of at least 2 days of perishable food supply of at least 7 days of nonperishable food supply. Sharps and medications were locked in secured areas. There was a first aid kit in the facility. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. The facility bathroom had available soap, paper towels,and trash cans with lids. The shower had grab bars, non-skid mats, and a shower chair. The water temperature in the bathroom sinks ranged from 113.3F - 116.4F. The water temperature in the showers ranged from 105.8F-117.6F. The water temperature in the kitchen sink was 117.1F. Two fire extinguishers were observed and both were inspected on January 2023. Facility smoke detectors were tested and found to be functioning when tested. Five out of five resident bedrooms had available bedding, drawers, and functioning lights. During tour of the resident's rooms, LPAs observed residents R1-R5 having half bed-rails or grab bars attached to the resident's bed. Licensee stated the residents use the bed-rails or grab bars for mobility. LPAs reviewed resident records for R1-R5, a physician's order was not obtained for the half-bed rails or grab bars. Per Licensee, the residents are not under the care of a Hospice agency. Licensee stated they will obtain physician's order for the half-side rails and grab bars which are attached to the resident's bed. See LIC809-C for more information. Page 1 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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 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: LOVELY CARE HOME	FACILITY NUMBER: 435201229
	VISIT DATE: 03/30/2023

NARRATIVE

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When touring the outside area of the facility, the exits were cleared of obstruction. LPAs observed a gas stove outside of the kitchen area. Per Licensee, the stove was installed 6 months ago and the purpose of the stove is to deep fry food items. Licensee stated they will remove the stove and propane tank. Licensee stated they will provide a picture of the area once the stove is removed to LPA Monter. LPAs inspected the storage areas outside of the facility and the storage units contained tools, cleaning products and no sign of area being used as a living quarter.

LPAs reviewed facility records for staff and residents. LPAs reviewed resident medications and central stored medication records. LPAs conducted interviews with 2 residents (R1-R2) and 1 staff (S1).

Advisory Notes and Technical Violation were issued. See LIC9102 pages for more information.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

This report was reviewed with Licensee Eliza Daquioag and a copy of the report was provided. Appeal Rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/30/2023 03:32 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: LOVELY CARE HOME	FACILITY NUMBER: 435201229
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

87608(a)(3) Postural Supports. A written order from a physcian indicating the need for the postural support shall be maintained in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 5 out of 5 residents have either half-side rails or grab bars attached to their bed without a written order from a physician, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2023
	Plan of Correction
1 2 3 4	Licensee stated they will submit a written order from a physician for R1-R5. Licensee will submit a written plan on facility's policy and procedure on obtaining a written order from physician for half-side rails and grab bars by the POC 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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3