<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202191
Report Date: 07/10/2024
Date Signed: 07/10/2024 04:49:26 PM

Document Has Been Signed on 07/10/2024 04:49 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NEWLIFE CARE SERVICES, INC. DBA NEWLIFE RCHFACILITY NUMBER:
435202191
ADMINISTRATOR/
DIRECTOR:		AMALIA AGUASFACILITY TYPE:
735
ADDRESS:4425 ADRAGNA COURTTELEPHONE:
(408) 832-3021
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 5DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Enrico Aguas TIME VISIT/
INSPECTION COMPLETED:
12:27 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
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Enrico Aguas.

All 5 residents were at day program. LPA reviewed 3 resident files and 3 staff files. One resident R1's medications is mismatched with the central stored medication form for 7/9/2024 PM medication, and the MAR does not document what happen for it..

LPA toured the facility inside out with ADM. License and personal rights posters were observed at main entrance. LPA observed expired Administrator Certificate, ADM provided the documents that he/she renewed the Administrator Certificate.

Living room, family room, kitchen, dinning area and two restrooms were inspected. Three shared resident bedrooms, garage, and laundry room were inspected. One staff live-in room was observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 76 degree F, and hot water temperature was at 108 degree F in facility.

Fire extinguisher was serviced on 08/02/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. Flash lights, first aid box and night lights were observed in the facility. The last time the facility conducted the emergency drill is 6/10/2024.
Deficiencies noted today. See LIC809-D .Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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 4
Document Has Been Signed on 07/10/2024 04:49 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 07/10/2024 at 12:16 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: NEWLIFE CARE SERVICES, INC. DBA NEWLIFE RCH
FACILITY NUMBER: 435202191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024

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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that resident R1's medications is mismatched with R1's central stored medication form for 7/9/2024 PM medication which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
1
2
3
4
ADM stated to submit a plan of correction by the POC due date and to provide training to staff, and to submit the training log by the 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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4