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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202124
Report Date: 07/19/2023
Date Signed: 07/19/2023 12:15:17 PM

Document Has Been Signed on 07/19/2023 12:15 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:BEYOND POTENTIAL LEARNING CENTERFACILITY NUMBER:
435202124
ADMINISTRATOR:CARMELA MAGPAYOFACILITY TYPE:
775
ADDRESS:1753 SOUTH MAIN STREETTELEPHONE:
(408) 438-0442
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 75CENSUS: 66DATE:
07/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Melissa RamosTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Manuel Monter, LPA Simi Rai and LPM Manzano conducted an unannounced annual inspection visit today, and met with Administrator Melissa Ramos.

During visit, ADM stated the facility has 66 clients total and 25 staff total. LPA toured the facility inside and out. Observed the activity area where the clients do morning zumba exercise. While observing the activity area wherein there were at least 64 clients with only few staff observed on the floor. The facility staff and resident ratio of 1:3 did not occur including a client observed in a quiet room unsupervised. After clients' morning activity, LPAs also observed staff taking clients to the van while other resident were being left unsupervised, and some staff were also observed not facing majority of the clients or there were no line of sight supervision. During visit, ADM was informed by staff lead that when LPAs and LPM facility, the staff were preoccupied in the staff room eating.

LPA observed cubicles where the clients can store their belongings; there are two restrooms. LPA observed toiletries and covers on the trash can. Measured hot water temperatures in both the men's and women's restrooms, between 118 to 119 degrees F.

The facility's Last disaster drill was conducted on 07/05/2023. There were 3 fire extinguishers observed in the facility and were last serviced in August 2021. ADM stated when the fire department came they state the fire extinguishers get serviced every 3 years.

Observed a dual fire alarm system with carbon monoxide detectors which in all areas. ADM stated that the properly landlord does the maintenance every six months. The facility has 14 transportation vans and are all being service at least every 3 months and as need.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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: BEYOND POTENTIAL LEARNING CENTER
FACILITY NUMBER: 435202124
VISIT DATE: 07/19/2023
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While touring the facility, LPA observed the carpeting in the activity room and other areas had wear and tare and had black circular stains and/or black spots. ADM stated that the black spots or stains on the carpet were due to food stains and ADM has spoken with the landlord last week but had denied the request to replace the carpet. ADM stated they are currently looking for vendors to replace carpet within 2-3 weeks.

LPA reviewed a random selection (5%)of clients and staff files. 4 Out 4 clients' records were reviewed and were complete such as Needs and Services Care plans and physicians assessments/TB clearances. 4 Out of 4 Staff files were reviewed with current training, required training, including first aid and CPR on file, physicians assessments/TB clearances, and are fingerprint cleared and associated.

Exit interview was conducted with Melissa Ramos, Deficiencies were cited today, See LIC 809-D. This report was provided to ADM for signature. Appeal rights were provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2023 12:15 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/19/2023 at 11:59 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: BEYOND POTENTIAL LEARNING CENTER
FACILITY NUMBER: 435202124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82078
82078 Responsibility for Providing care and supervision (a) the licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement.

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 during inspection, several residents who were not supervised and 1 resident in the sick room without supervision, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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ADM stated she will have a staff meeting addressing the lack of supervision, lack of ratio in the facility, lack of lines of sight while working and will send itinerary to LPA, with staff signitures.
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: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
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