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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201842
Report Date: 04/24/2024
Date Signed: 04/24/2024 10:56:29 AM

Document Has Been Signed on 04/24/2024 10:56 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:EDWARD CARE HOMEFACILITY NUMBER:
435201842
ADMINISTRATOR/
DIRECTOR:		QUINTIN H. ZACARIASFACILITY TYPE:
735
ADDRESS:1315 BECKET DRIVETELEPHONE:
(408) 224-9988
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 4DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:55 AM
MET WITH:Administrator Remedios ZacariasTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Remedios Zacarias . During the visit, LPA observed 0 residents and 2 staff.

LPA toured the facility inside out with ADM 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. There was no obstruction to block the walkways.

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 70 degrees F, and hot water temperature was measured at 118 degrees F in both resident bathrooms.

While touring the residents bedrooms, LPA observed resident bedroom across from the hallway bathroom, has damaged blinds. (Photograph was taken.) While touring the deck, LPA observed a small hole the size of a quarter. LPA also observed one of the wooden planks dipped a when you stepped on it. (Photographs were taken.) LPA also observed the window screen, for the bathroom closest to the deck was missing. (Photograph was taken.)

Fire extinguisher was serviced in September 28, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last fire/disaster/earthquake drills conducted for the year 2023 & 2024 were on the following dates; February 20, 2024 and March 9, 2024. (Photographs were taken.) LPA asked ADM if these were the facility records for fire/disaster/earthquake drills. ADM confirmed those were the records. Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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: EDWARD CARE HOME
FACILITY NUMBER: 435201842
VISIT DATE: 04/24/2024
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LPA reviewed facility records for 3 staff & 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records. LPA conducted interviews with 1 staff and 0 residents. (Residents were attending day program during LPA's visit.)

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Remedios Zacarias 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: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2024 10:56 AM - It Cannot Be Edited


Created By: Manuel Monter On 04/24/2024 at 10:19 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: EDWARD CARE HOME
FACILITY NUMBER: 435201842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024

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
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Based on observation, the licensee did not comply with the section cited above. LPA observed resident bedroom across from the hallway bathroom, has damaged blinds. LPA observed at the facility deck, a small hole the size of a quarter and a wooden plank that dipped a when you stepped on it. LPA also observed the window screen, for the bathroom closest to the deck was missing. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure the facility is in good repair at all times. ADM stated her plan of action will address the following; the bathrooms missing screen, the resident's bedrooms damaged blinds, the damaged wood planks in the deck. ADM stated she will send LPA photographs showing the issues have been addressed. ADM stated she will send her plan of action by POC date, May 1, 2024.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. The facility's last fire/disaster/earthquake drills conducted for the year 2023 & 2024 were on the following dates; February 20, 2024 and March 9, 2024. LPA asked ADM if these were the facility records for fire/disaster/earthquake drills. ADM confirmed those were the records. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure a drill is conducted quarterly. ADM stated she will send the written plan of action by POC date, May 1, 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: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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