<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201710
Report Date: 08/14/2024
Date Signed: 08/14/2024 11:28:04 AM

Document Has Been Signed on 08/14/2024 11:28 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:KERN A.R.F.FACILITY NUMBER:
435201710
ADMINISTRATOR/
DIRECTOR:		SASHI KUMARFACILITY TYPE:
735
ADDRESS:2785 KERN AVE.TELEPHONE:
(408) 281-7057
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrative Assistant Ernie ManoiasTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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) Manuel Monter and Marcela Yanez conducted an unannounced annual inspection visit, and met with Administrative Assistant (AA) Ernie Manaois. During the visit, LPA observed 6 residents and 1 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with staff S1 which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected.

While touring the backyard, LPA's observed the exit to the front of the home, near the garage was obstructed by a fridge, washing machine and bicycle. AA stated he needs to schedule with the county to pick up those items. LPA also observed the backyard ramp had wooden planks, which was part of the walkway, was damaged. The damaged wooden planks sink when stepped on. LPA's also observed bedroom #3 and #2 does not have sliding screen doors. (Photographs were taken.)

While touring resident bedroom #3, LPA observed a bag of "FOCA" laundry detergent, right next to a residents bed.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 78 degrees F, and hot water temperature was measured at 110 degrees F in resident bathroom.


Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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 5
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: KERN A.R.F.
FACILITY NUMBER: 435201710
VISIT DATE: 08/14/2024
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
26
27
28
29
30
31
32
While touring the facility kitchen, LPA observed 3 live cockroaches in the facility kitchen. 2 cockroaches were observed next to the facility stove, and another was observed above the facility sink. AA stated the facility's have had cockroaches for a month. AA stated they have not hired a licensed professional for treatment. AA stated the facility is using traps and spraying.

Fire extinguisher was serviced in 06/24/2024 The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by AA, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on July 30, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA conducted interviews with 1 staff and 1 residents. LPA's requested to review resident R1-R3's centrally stored medication record.

LPA requested to reviewed 3 resident medications and centrally stored medication records. LPA's reviewed the facility's centrally stored medication record and observed that R2's centrally stored medication log was not updated. Resident R1 and R3 did not have centrally stored medication log. AA stated he does not use the centrally stored medication record. AA stated he only has the Medication Administration Record.

Deficiencies are being cited during today's visit. This report was reviewed with Administrative Assistant Ernie Manoias and a copy of the signed report was provided. Appeal rights were provided.

Page 2 Out of 2.

END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/14/2024 11:28 AM - It Cannot Be Edited


Created By: Manuel Monter On 08/14/2024 at 10:41 AM
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: KERN A.R.F.
FACILITY NUMBER: 435201710

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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. LPA observed inside resident bedroom #3, a bag of "FOCA" laundry detergent, right next to a residents bed. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
1
2
3
4
ADM stated he will send a written plan of action on how he will ensure Disinfectants, cleaning solutions, poisons, firearms are inaccessible to residents in care. ADM stated he will send the written plan of action by POC date, August 15, 2024.
Type A
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

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. LPA's reviewed the facility's centrally stored medication record and observed that R2's centrally stored medication log was not updated. Resident R1 and R3 did not have centrally stored medication log. AA stated he does not use the centrally stored medication record. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
1
2
3
4
ADM stated he will send an updated centrally stored medication record for R1, R2 and R3. ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will send the plan of correction to LPA by POC date, August 15, 2024.
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
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/14/2024 11:28 AM - It Cannot Be Edited


Created By: Manuel Monter On 08/14/2024 at 10:41 AM
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: KERN A.R.F.
FACILITY NUMBER: 435201710

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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. LPA also observed the backyard ramp had wooden planks was damaged. The damaged wooden planks sink when stepped on. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
1
2
3
4
ADM stated he will send a written plan of action on how he will ensure the facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. ADM stated he will send photo documentation showing the wooden planks for the ramp in the backyard have been fixed. ADM stated he will send the plan send LPA the plan of correction by POC date, August 21, 2024.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

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. LPA observed 3 live cockroaches in the facility kitchen. 2 cockroaches were observed next to the facility stove, and another was observed above the facility sink. AA stated the facility's have had cockroaches for a month. AA stated they have not hired a licensed professional for treatment. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
1
2
3
4
ADM stated he will send a written plan of action on how he will keep the facility free of cockroaches and other insects. ADM stated he will send LPA a written plan of action by POC date, August 21, 2024.
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
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/14/2024 11:28 AM - It Cannot Be Edited


Created By: Manuel Monter On 08/14/2024 at 10:41 AM
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: KERN A.R.F.
FACILITY NUMBER: 435201710

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard 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. LPA's observed the exit to the front of the home, near the garage was obstructed by a fridge, washing machine and bicycle. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
1
2
3
4
ADM stated he will send a written letter of understanding regarding the regulation, and the importance of keeping All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas free of obstruction. ADM stated he will send photo documentation showing the passageway next to the garage is cleared. ADM stated he will send the written letter of understanding by POC date, August 21, 2024.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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. LPA's also observed bedroom #3 and #2 does not have sliding screen doors. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
1
2
3
4
ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will send photo documentation showing resident bedrooms #2 and #3 have their sliding screen doors. ADM stated he will send the plan of correction by POC date, August 21, 2024.
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
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5