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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201958
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:01:17 PM

Document Has Been Signed on 07/03/2024 04:01 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:CATHELEEN RCH-I & II DBA:CATHELEEN RCH IIFACILITY NUMBER:
435201958
ADMINISTRATOR/
DIRECTOR:
JULIUS ERVIN JAVIERFACILITY TYPE:
735
ADDRESS:2513 SHILSHONE CIRCLETELEPHONE:
(408) 294-1296
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Administrator Julius Ervin JavierTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Julius Ervin Javier. During the visit, LPA observed 4 residents and 3 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. LPA measured facility Room temperature was at 90 degrees F using a thermometer. LPA observed the facility thermostat, which indicated the facility temperature was at 89 degrees F. LPA measured facility hot water temperature at 108 degrees F in both resident bathrooms.

Fire extinguisher was serviced in January 11, 2024. 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 drill was on May 20, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. While reviewing resident R1 and R3's centrally stored medication log, LPA observed the log was not filled out. ADM stated he did not fill out the log for R1 and R3, but was planning on filling out the logs today. LPA conducted interviews with 2 staff and 2 residents. LPA reviewed 3 resident P&I records.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Julius Ervin Javier and a copy of the signed report was provided. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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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Document Has Been Signed on 07/03/2024 04:01 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/03/2024 at 03:46 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: CATHELEEN RCH-I & II DBA:CATHELEEN RCH II

FACILITY NUMBER: 435201958

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(a)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA measured facility Room temperature was at 90 degrees F using a thermometer. LPA observed the facility thermostat, which indicated the facility temperature was at 89 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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ADM stated he will send a written plan of action on how he will ensure the facility temperature in rooms that clients occupy are at the temperature range between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). ADM stated he will also get a portable air conditioners and send LPA a copy of the receipts. ADM stated he will send the plan of correction by POC date, July 4, 2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/03/2024 04:01 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/03/2024 at 03:46 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: CATHELEEN RCH-I & II DBA:CATHELEEN RCH II

FACILITY NUMBER: 435201958

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

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. Resident R1 and R3's centrally stored medication log was observed to be not filled out. ADM stated he did not fill out the log and was planning on filling out the logs today. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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ADM stated he will send a written letter of understanding regarding the regulation. ADM stated he will send the plan of correction by July 10, 2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024


LIC809 (FAS) - (06/04)
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