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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201710
Report Date: 06/28/2023
Date Signed: 06/28/2023 03:39:11 PM

Document Has Been Signed on 06/28/2023 03:39 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:KERN A.R.F.FACILITY NUMBER:
435201710
ADMINISTRATOR:SASHI KUMARFACILITY TYPE:
735
ADDRESS:2785 KERN AVE.TELEPHONE:
(408) 281-7057
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
06/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Ernie ManaoisTIME COMPLETED:
03:44 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle conducted an unannounced case management at the facility. LPA met with facility Administrator Ernie Manaois (Admin).

LPA arrived at the facility to open a complaint investigation regarding a separate matter. During the complaint investigation, LPA observed a lock on the facility refrigerator. Admin confirmed that the facility has locks on all refrigerators and pantries to ensure that residents do not eat too much food at night.

LPA asked Admin if there were any residents at the facility diagnosed as food seeking, or otherwise needing restricted access to food. Admin stated that there were no residents at the facility with such diagnoses. LPA clarified to Administrator that residents at the facility shall have access to food at all times.

Administrator acknowledged understanding, and removed all locks from food storage cites located within the kitchen.

Deficiency cited, see 809-D, this report was reviewed with facility Administrator Ernie Manaois and a signed copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
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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Document Has Been Signed on 06/28/2023 03:39 PM - It Cannot Be Edited


Created By: Ryker Heberle On 06/28/2023 at 03:25 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: KERN A.R.F.
FACILITY NUMBER: 435201710

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2023
Section Cited
CCR
80072(a)(3)

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80072 - Personal Rights - (a) To be free from... unusual punishment... including but not limited to: interference with the daily living functions, including eating... This requirement is not met as evidenced by:
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CORRECTED DURING INSPECTION
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Based on LPA observation, the facility did not adhere to the above regulation by locking facility refrigerators and pantries. This posed a potential risk to the health and safety of residents in care.
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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:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023


LIC809 (FAS) - (06/04)
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