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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201925
Report Date: 02/09/2024
Date Signed: 02/09/2024 01:12:07 PM

Document Has Been Signed on 02/09/2024 01:12 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:HELPING HANDS RESIDENTIAL CARE HOME FOR ADULTSFACILITY NUMBER:
435201925
ADMINISTRATOR:JANESSA FLORESFACILITY TYPE:
735
ADDRESS:3072 CENTERWOOD WAYTELEPHONE:
(408) 813-1626
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 4DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator (ADM) Janessa FloresTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Janessa Flores. LPA Rai observed 1 staff and 1 resident at the facility and 3 residents were attending day program.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas.

LPA Rai toured the resident bedrooms. 4 out of 4 resident bedrooms had available bedding, drawers, and functioning lights. Based on the review of the facility sketch submitted to the Department and today's observations, bedroom #1 has been converted to a living room and staff bedroom has been converted into the resident room. ADM will submit an updated facility sketch.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 106.4F - 118.4F. The water temperature in the kitchen sink was 121.5F.

Fire extinguisher was observed and bought new on 2/11/2023. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 01/26/2024.

LPA Rai reviewed resident medications and central stored medication records.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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: HELPING HANDS RESIDENTIAL CARE HOME FOR ADULTS
FACILITY NUMBER: 435201925
VISIT DATE: 02/09/2024
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LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai observed 1 out of 3 resident files (R1) did not contain a signed Admission Agreement. LPA Rai observed 1 out 3 resident files (R3) did not contain a signed Needs and Services Plan.

During resident record review, R2 & R3 have restricted health condition wherein the resident is not able to take care of condition due to mental capability, LPA Rai reviewed CCR 80092.4 Colostomy/Ileostomy and 80092 Restricted Health Conditions with ADM and to follow the requirements under the regulations.

Deficiencies were cited per California Code of Regulations, Title 22, see LIC 809-D. This report was reviewed with Administrator (ADM) Janessa Flores. A copy of the report and Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/09/2024 01:12 PM - It Cannot Be Edited


Created By: Simranjit Rai On 02/09/2024 at 12:47 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: HELPING HANDS RESIDENTIAL CARE HOME FOR ADULTS
FACILITY NUMBER: 435201925

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

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 in 1 out of 3 resident files did not contain a signed Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Administrator stated to submit a written plan of action and understand regulations by POC due date. Adminstrator agreed and understood.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

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 in 1 out of 3 resident files did not contain a signed Needs and Service Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Administrator stated to submit a written plan of action and understand regulations by POC due date. Adminstrator agreed and understood.
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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
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