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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201933
Report Date: 12/28/2023
Date Signed: 12/28/2023 02:12:42 PM

Document Has Been Signed on 12/28/2023 02:12 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:HOPE SERVICES-LAS COLINAS ADULT DAY PROGRAMSFACILITY NUMBER:
435201933
ADMINISTRATOR:CAROLYN JEAN FILIATRAULTFACILITY TYPE:
775
ADDRESS:30 LAS COLINAS LANETELEPHONE:
(408) 284-2850
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 55CENSUS: 38DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Program Manager, Lauro CentenoTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst Simi Rai conducted an unannounced Required 1 Year visit and met with Program Manager (PM) Lauro Centeno. LPA observed 9 staff and 25 residents in the activity room of the facility.

During visit, LPA toured the facility inside and out. Sharps and medications were locked in secured areas.
The facility restrooms had available soap, paper towels and hand sanitizer. Hot water temperature was tested and measured 105.2 - 107.6 F degrees. Exercise equipment was also observed. Refrigerators were available to store clients' food in the kitchen area.

Fire extinguisher was observed and inspected on January 18th 2023. Facility smoke detectors and carbon monoxide detectors were in working condition. First aid kits were inspected and observed compliant to regulations. The facility's last disaster drill was not documented but PM stated the facility participated in the Statewide Shake Out this year.

LPA Rai reviewed 5 client files. LPA reviewed Client's Medication Administration Record for 2 clients, R1-R2. During review of R3's client file, R3 did not have a copy of the Admission Agreement, LIC 613 Personal Rights and consent form on file.

LPA Rai reviewed 5 staff files. LPA Rai reviewed S1's staff file, S1 does not have criminal record clearance and health screening report. PM stated the facility was aware of a background clearance but was not aware of S1 not having criminal record clearance. LPA Rai informed PM of S1 not working in the facility until criminal record clearance is obtained.


Continuation on LIC 809-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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 7
Document Has Been Signed on 12/28/2023 02:12 PM - It Cannot Be Edited


Created By: Simranjit Rai On 12/28/2023 at 11:13 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: HOPE SERVICES-LAS COLINAS ADULT DAY PROGRAMS
FACILITY NUMBER: 435201933

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain 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 record review, the licensee did not comply with the section cited above in Resident R3's file did not have Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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Progam Manager stated the client will sign the form and file in R3's file and submit a plan of action by POC due date. Program Manager agreed and understood.
Type B
Section Cited
CCR
82072(a)
Personal Rights
(a) Each client shall have personal rights which include, but are not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in Resident R3's file did not have LIC 613 Personal Rights form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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Progam Manager stated the client will sign the form and file in R3's file and submit a plan of action by POC due date. Program Manager 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: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/28/2023 02:12 PM - It Cannot Be Edited


Created By: Simranjit Rai On 12/28/2023 at 11:13 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: HOPE SERVICES-LAS COLINAS ADULT DAY PROGRAMS
FACILITY NUMBER: 435201933

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82023(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

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 disaster drills were not documented on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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Program Manager stated the facility will conduct a disaster drill and submit a plan of action by POC due date. Program Manager agreed and understood.
Type B
Section Cited
CCR
80075(h)(4)
(h) There shall be at least one person capable of and responsible for communicating with emergency personnel in the facility at all times. The following information shall be readily available: (4) It is recommended that the licensee obtain consent forms to permit the authorization of medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Resident R3's file did not have consent form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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Progam Manager stated the client will sign the form and file in R3's file and submit a plan of action by POC due date. Program Manager 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: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/28/2023 02:12 PM - It Cannot Be Edited


Created By: Simranjit Rai On 12/28/2023 at 12:37 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: HOPE SERVICES-LAS COLINAS ADULT DAY PROGRAMS
FACILITY NUMBER: 435201933

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(g)(2)
80065 Personnel Requirements
(g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.
(2) A health screening report signed by the person performing such screening shall be made on each person specified above...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 employee files did not have Health Screening on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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Progam Manager stated the 3 employees will schedule a health screening visit and submit report along with a plan of action by POC due date. Program Manager agreed and understood.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 12/28/2023 02:12 PM - It Cannot Be Edited


Created By: Simranjit Rai On 12/28/2023 at 12:45 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: HOPE SERVICES-LAS COLINAS ADULT DAY PROGRAMS
FACILITY NUMBER: 435201933

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(2) Obtain a California clearance or a criminal record exemption as required by the Department.

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 S1 did not have California Criminal Record Clearance on file and status is incomplete which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Program Manager will take staff S1 off scheule until S1 has Criminal Record Clearance and submit a plan of action by POC due date. Program Manager agreed and understood.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


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: HOPE SERVICES-LAS COLINAS ADULT DAY PROGRAMS
FACILITY NUMBER: 435201933
VISIT DATE: 12/28/2023
NARRATIVE
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Page 2 of 2.

LPA Rai reviewed S3's staff file and S5's staff file and both files did not have health screening report. Per PM, both employees have worked at the facility 10+ years and Human Resources cannot find the report. 5 Out of 5 staff have TB clearance on file.

Technical Assistance was provided.

A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S1) working at the facility without criminal record clearance. Please see LIC 421BG.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
Exit interview was conducted with Program Manager, Lauro Centeno and Program Coordinator, Kenneth Hooper. A copy of this report was provided to Program Manager, Lauro Centeno. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
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