435201885-7-27-2024-26-AS-MPAA-D7KRAJ-20240727125112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201885
Report Date: 07/27/2024
Date Signed: 07/27/2024 12:51:37 PM

Document Has Been Signed on 07/27/2024 12:51 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:	NEW HAVEN RESIDENTIAL CARE FACILITY #2		FACILITY NUMBER:	435201885
ADMINISTRATOR/ DIRECTOR:	DARLINGTON ODJEGBU		FACILITY TYPE:	735
ADDRESS:	5842 CADIZ DRIVE		TELEPHONE:	(408) 578-8804
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 6		CENSUS: 3	DATE:	07/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:25 AM
MET WITH:	Darlington Odjegbu - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:50 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	On 07/26/2024 at 8:28 a.m.. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived and conducted an unannounced required 1 year inspection visit. LPA was greeted by 2 staff (S1, S2). LPA stated the purpose of the visit to the staff. S1 stated that ADM was not in the facility and called the administrator (ADM) Darlington Odjegbu. ADM arrived at the facility at approximately 8:42 a.m. The facility is a Adult Residential Facility (ARF) licensed to serve ages 18 through 59. Facility is licensed to serve 6 developmentally disabled adults and all may be non-ambulatory. 2 staff were present at the time of the visit. The facility has 3 ambulatory resident who are developmentally disabled. At 8:31 a.m. LPA toured the facility inside and outside with staff and ADM, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, backyard and walkways. The temperature inside the home was at 78 degrees F. LPA and ADM toured the 2 bathroom and 4 bedroom. 3 out 4 bedroom is utilized by the residents and 1 of 4 bedroom is used by staff. The facility has 2 NOC (nocturnal) shift staff. LPA observed 3 of 3 residents bedrooms to be organized, sanitary and free from any debris and has sufficient storage for residents' personal belongings. LPA observed that 1 of 3 bedroom floor bedroom has sliding door that easily opens and are free from obstruction. LPA observed that the facility has smoke and carbon monoxide alarm system that was tested by the staff and found to be in good working condition. Hallways are free from obstruction. LPA observed ramps and walkways are free from obstruction. LPA observed the backyard area to be free from debris, however the pathway has a concrete slab that was coming off the ground due to root heave, the tiles by backyard are coming off. ADM stated that the uneven walkway pavement will be fixed but would take time and the tiles that are coming off will be replaced or re-paved. page 1 of 2

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

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: NEW HAVEN RESIDENTIAL CARE FACILITY #2	FACILITY NUMBER: 435201885
	VISIT DATE: 07/27/2024

NARRATIVE

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LPA with ADM toured 2 full bathrooms on the ground floor to have anti skid mats and grab bars and with sufficient supply of paper towels and toiletries.

LPA tested the water temperature for kitchen and bathrooms, water temperature measured at 112 degrees F to 115 degree F. Dining and kitchen area and living room area were observed to be sanitary and organized. The facility has sufficient supply of perishable food for 2 days and non-perishable food for 7 days. The fire extinguishers was inspected on 7/26/2024. LPA observed knives are in a locked drawer not accessible to residents.

LPA and ADM inspected the laundry area. LPA observed the laundry area is located inside the garage and are in good working condition. Cleaning supplies and detergents were separated and in a locked cabinet. LPA observed the medication cabinet is locked and is not easily accessible. LPA observed first aid kit to be complete and easily accessible.

LPA reviewed facility record, 2 staff record and 3 resident records. Facility's earthquake and fire drill training conducted on 5/12/2024 and 5/15/2024. Staff training records were up to date. Staff records were reviewed with current first aid certifications, clearance and training. Residents files were reviewed to be complete. Residents' medications are labeled and current. LPA with ADM reviewed 3 of 3 resident's cash resources and found that 3 of 3 resident's cash resources are not accurate. The money count was over for 3 of 3 of resident's cash resource. Staff record was missing notice of employee rights. LPA discussed with ADM the importance of keeping the record accurate and have given a technical advisory for the record maintenance.
LPA discussed with ADM the importance of maintaining the outdoor ground pavement free of tripping hazard for the safety of residents, employees and visitors.

LPA Requested for the update of the following: LIC 500, LIC 308, lease agreement for the property.

Deficiency was cited during today's visit per California code of regulations (CCR) Title 22. See LIC 809D. An exit interview was conducted with administrator Darlington Odjegbu and a copy of the report and appeals rights were provided.
page 2 of 2 (end of report)

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 07/27/2024 12:51 PM - It Cannot Be Edited

Created By: Maria Partoza On 07/27/2024 at 12:13 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: NEW HAVEN RESIDENTIAL CARE FACILITY #2	FACILITY NUMBER: 435201885
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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 by not maintaining the following; The bathroom has broken tiles at the back of the toilet seat. Tile were coming off on the backyard patio pavement, a block of concrete on the pathway at the back yard has uneven surface due to root heave. The uneven surface is a trip hazard to people walking on the pavement which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2024
	Plan of Correction
1 2 3 4	Administrator stated that the root heave (block of concrete that popped out of the ground), the tiles that are coming off the ground and broken along with the bathroom tile behind the toilet seat will be scheduled with their maintenance person and contractor. A plan of correction to schedule on how the deficiencies will be addressed will be submitted by the adminstrator by the plan of correction (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:

Romeo Manzano

LICENSING EVALUATOR NAME:

Maria Partoza

LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

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