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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201646
Report Date: 05/14/2024
Date Signed: 05/14/2024 11:34:51 AM

Document Has Been Signed on 05/14/2024 11:34 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:K & N MANOR, INC.FACILITY NUMBER:
435201646
ADMINISTRATOR/
DIRECTOR:		REMEDIOS BOSEFACILITY TYPE:
735
ADDRESS:2420 BRIDLE PATH DRIVETELEPHONE:
(408) 846-0819
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 5DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Remedios BoseTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator, Remedios Bose.

LPA toured the facility with staff to include the resident bedrooms, staff bedrooms, bathroom, living rooms, kitchen, laundry room, and backyard. All fire exit routes are free and clear of obstruction. Facility staff present are fingerprint cleared. In-ground pool in the backyard observed locked and fenced. The in-ground pool does not contain water.

Facility temperature maintained at 71 degrees Fahrenheit. Fire Extinguisher last serviced on 06/20/2023. Facility has a carbon monoxide detector. Sharp objects observed secured. Medications observed in a locked cabinet. Chemicals, disinfectants, and toxins observed locked. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Freezer temperature maintained below -18 degrees Celsius. Refrigerator temperature maintained at 3 degrees Celsius.

Resident bedrooms observed clean and well-kept. Bedrooms equipped with beds, linens, dressers, closet space, adequate lighting, and night stands. Bathroom hot water temperature maintained at 116 degrees Fahrenheit. Toilets and shower observed clean and sanitary. Shower observed with a non-slid mat.

Facility has an emergency disaster plan. LPA observed the residents grab-and-go backpacks. Facility conducts emergency disaster drills quarterly and the last drill was conducted on 03/10/2024. LPA observed a first aid to be complete and emergency lighting. Facility has an infection control plan. Personal Protective Equipment (PPE) supplies observed to include gowns, shields, N95 masks, and hand sanitizers. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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: 05/14/2024
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LPA reviewed 3 resident files contained the following: face sheet, emergency information, admission agreement, physician's report, TB, appraisal needs and services plan/IPP, personal rights, consent forms, weight record, safeguard of personal property and valuables, safeguard of cash resources, and centrally stored medication records. LPA observed 3 out of 3 residents P&I money and centrally stored medications were maintained.

LPA reviewed 3 staff files contained the following: health screening record, TB result, criminal record statement, 1st aid certification, and training records.

The following documents were requested to include the emergency disaster plan, resident roster, liability insurance, and LIC500.

No deficiencies are cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Remedios Bose and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
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