435201493-6-21-2024-26-AS-MPAA-D6FQJN-20240621121301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201493
Report Date: 06/21/2024
Date Signed: 06/21/2024 12:13:19 PM

Document Has Been Signed on 06/21/2024 12:13 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:	A HEAVENLY CARE HOME		FACILITY NUMBER:	435201493
ADMINISTRATOR:	FONTANILLA, DIANA		FACILITY TYPE:	740
ADDRESS:	259 CHECKERS DRIVE		TELEPHONE:	(408) 926-3285
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY:	6	CENSUS: 3	DATE:	06/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Diana Fontanilla - Administrator		TIME COMPLETED:	12:15 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	On 6/21/2024 at 8:30 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived and conducted an unannounced required 1 year inspection visit. LPA was greeted by 1 staff and Administrator (ADM) Diana Fontanilla. LPA stated the purpose of the visit with ADM. The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over 6 non-ambulatory, 1 may be bedridden and a waiver for 3 hospice care. The facility has 3 residents (R1 to R3) that have neurocognitive impairment and are non-ambulatory. 2 staff were present at the time of the visit. 3 residents were present at the facility and 2 out of 3 were in their bedroom resting and watching TV. 1 out of 3 was asleep. LPA was able to interview 2 out of 3 residents. At 8:55 a.m. LPA toured the facility inside and outside with ADM, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, staff room, backyard and walkways. LPA observed the Personal Rights disclosure, Long Term Care Ombudsman (LTCO) and Centralized Complaint and Information Bureau (CCIB) of the CA Department of Social Services (CDSS) prominently posted on the wall, visible to visitors, resident and staff. The temperature inside the home was at 68 to 69.8 degrees F. LPA and ADM toured the 3 resident bedroom and 1 staff room. LPA observed the rooms to be organized and free from debris and has sufficient storage for resident's personal belongings. Resident's bedroom has a bell call system to alert staff if assistance is needed. Bedroom #3 have an exit door and are free from obstruction. 1 of 3 bedroom is shared by 2 residents. 2 out 3 bedroom are private rooms. LPA observed 3 out of 3 residents' bed linens was recently changed and organized and sanitary. page 1 of 2 (see LIC809C).

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

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 2

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: A HEAVENLY CARE HOME	FACILITY NUMBER: 435201493
	VISIT DATE: 06/21/2024

NARRATIVE

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LPA observed that the facility has a wall pull fire alarm system connected to the fire department emergency line and a carbon monoxide alert system that is in good working condition. LPA observed night lights on the hallway. Hallways are free from obstruction. The sliding door going out to the backyard slides easily and free from obstruction. LPA observed ramps and walkways are free from obstruction. LPA observed the backyard area to be free from debris and is maintained. LPA observed the backyard fence is currently being repaired.

LPA with ADM toured 2 full bathrooms (B1, B2). LPA observed B1 and B2 have non-skid mats and grab bars and a raised toilet seat . The facility stores incontinent supplies, cleaning and laundry detergents in a locked cabinet not easily accessible to residents in care. LPA with ADM inspected the staff room and found the room to be organized and sanitary.

LPA was not able to measure the water temperature at the time of the visit due to scheduled maintenance. Dining and kitchen area and living room area were observed to be sanitary and organized. The facility has sufficient supply of perishable food for 2 days and non-perishable food for 7 days. The fire extinguisher located in the kitchen was bought on 1/1/2024.

LPA and ADM inspected the laundry area located in the garage and door is kept locked with alarm for resident's safety. The washer and dryer are in good working condition LPA with ADM inspected the medication cabinet. LPA observed the medication cabinet is locked and is not easily accessible. LPA observed first aid kit was complete and stored with the PPEs. LPA observed a staff in the kitchen during the time of visit and staff showed LPA that knives are locked after use.

LPA reviewed facility record, 2 out of 2 staff record and 3 out of 3 resident record.
Facility's fire drill training conducted on 6/8/2024, facility records are up to date. Staff training records were up to date. Staff records were reviewed with current first aid certifications, clearance and training. Residents files were reviewed to be complete. Residents' medications are labeled and current.

No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with administrator Diana Fontanilla. A copy of the report were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC809 (FAS) - (06/04)

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