435201646-4-25-2023-26-AS-CDOS-CR92TY-20230425174130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201646
Report Date: 04/25/2023
Date Signed: 04/25/2023 05:41:55 PM

Document Has Been Signed on 04/25/2023 05:41 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:	K & N MANOR, INC.		FACILITY NUMBER:	435201646
ADMINISTRATOR:	SEDIGH, MALOU		FACILITY TYPE:	735
ADDRESS:	2420 BRIDLE PATH DRIVE		TELEPHONE:	(408) 846-0819
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY: 6		CENSUS: 5	DATE:	04/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Romedios Bose		TIME COMPLETED:	05:50 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 Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection. LPA met with Administrator, Remedios Bose. During visit, LPA toured the facility with Administrator to include the living room, kitchen, dining room, hallway, resident bedrooms, bathroom, laundry room, staff bedrooms, garage, and backyard. All fire exit routes and passageways were free and clear of obstruction. Facility staff present and live-in staff are fingerprint cleared and associated to the facility. Facility temperature maintained at 70 degrees Fahrenheit. Fire Extinguisher last serviced on 07/29/2022. Facility did not have an operable carbon monoxide detector. During visit, the carbon monoxide detector was replaced and observed operable. Medications observed in a locked cabinet. Kitchen supplied with plates, bowls, cups, utensils, and cooking supplies. LPA observed the cabinet equipped with sharp objects and the sharp objects was dirty with dirt, spider webs, and deceased insects. Staff first stated they wash the knives before use, however, upon follow-up it was found the staff actually use a different set of knives located in the locked staff living quarters. LPA observed the knives was clean. Administrator was advised. Facility has at least 7 days worth of non perishable foods and 2 days worth of perishable foods. Food storage containers observed with a lid and labeled. Facility does not have a thermometer inside the refrigerator and freezer to record temperature. Administrator was advised. LPA observed the cabinets which stored non-perishable foods were locked. Staff state a couple clients has behaviors in opening the cabinets and throwing / moving around items. Staff state clients are always given snacks upon request. During visit, the Administrator created a bin of accessible snacks for the residents and unlocked the cabinets. Administrator was advised and stated understanding. SEE LIC809-C.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: K & N MANOR, INC.	FACILITY NUMBER: 435201646
	VISIT DATE: 04/25/2023

NARRATIVE

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Bathrooms supplied with hygiene products, paper supplies, and lidded trash bins. Toilets and shower observed clean and sanitary. Hot water temperature at the bathroom sink maintained at 122.1 degrees Fahrenheit.

Resident bedrooms observed clean and well-kept. Bedrooms equipped with beds, linens, dressers, closets, and night stands. LPA observed room #1, #2, and #4 did not have adequate lighting. RM #1 observed with one small lamp shade. RM #2 observed with 1 medium lamp shade for 2 residents. RM #4 observed with a ceiling light that took about 30 seconds to brighten. Administrator was advised.

Facility has an emergency disaster plan. LPA observed the residents grab-and-go backpack located near the entrance. Facility's last emergency drill was conducted on 06/2022. Administrator was advised.

LPA reviewed 3 resident (R1 - R3) files to contain the following: face sheet, emergency information, admission agreement, physician's report, TB, appraisal needs and services plan, personal rights, consent forms, weight record, immunization, safeguard of personal property and valuables, safeguard of cash resources, and centrally stored medication records. LPA inspected R1 - R3's P&I money and centrally stored medications. Administrator was advised to ensure client's appraisal needs and services plan are maintained current and accurate.

LPA reviewed 3 staff (S1 - S3) files to contain the following: health screening record, TB, criminal record statement, 1st aid certification, and training records. LPA did not observe staff were provided annual training to include medication administration. Administrator states they have an upcoming training scheduled with the Regional Center on 05/02/2023 and 05/11/2023. Administrator was advised.

LPA interviewed 1 resident and 3 staff members.

Documents to be submitted to LPA Dolores includes change of Administrator documents.

A deficiency is being cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Administrator, Remedios Bose and a copy of the report and appeal rights was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/25/2023 05:41 PM - It Cannot Be Edited

Created By: Christine Dolores On 04/25/2023 at 05:13 PM

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: K & N MANOR, INC.	FACILITY NUMBER: 435201646
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1503.2

General Provisions

Every facility licensed or certified pursuant to this chapter 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
1 2 3 4	Based on observation the facility's carbon monoxide detector was observed not in an operable condition which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2023
	Plan of Correction
1 2 3 4	Administrator replaced the carbon monoxide detector. Licensee will submit their written plan to ensure they have an operating cabon monixide detector going forward, to LPA by POC due 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:

Sarah Yip

LICENSING EVALUATOR NAME:

Christine Dolores

LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

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