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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202293
Report Date: 06/27/2024
Date Signed: 06/28/2024 08:02:26 AM

Document Has Been Signed on 06/28/2024 08:02 AM - 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:KB CARE HOMEFACILITY NUMBER:
435202293
ADMINISTRATOR/
DIRECTOR:		KAITLYN BROWNELLFACILITY TYPE:
735
ADDRESS:1948 SEABEE PLACETELEPHONE:
(408) 823-6734
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 4DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:39 PM
MET WITH:Myrna BrownellTIME VISIT/
INSPECTION COMPLETED:
04:39 PM
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Licensing Program Analyst (LPA) Steve Chang conducted a unannounced annual inspection visit and met with staff Myrna Brownell (S1).

LPA observed license and personal rights posters in the facility. LPA did not see Administer Certificate in the facility. Administrator (ADM) Kaitlyn Brownell stated on the phone that he/she renewed it and sent the document already. S1 showed a copy of the check that ADM paid for renewal fee of ADM Certificate. ADM stated he/she will provide all the necessary documents later.

LPAs checked 2 resident files and 2 staff files. Resident R1's appraisal/needs and service plan was completed on year 2020 and resident R2's appraisal/needs and service plan was completed on year 2021. LPA did not see resident R2's Admission Agreement. ADM stated on the phone that he/she will send to LPA via email. LPA observed 4 staff and 4 residents in the facility.

LPA toured the facility inside out with S1. LPA toured living room, family room, kitchen, dinning area, and laundry room. Medication closet, knives closet, and cleaning product closet were observed locked.

There are 3 resident bedrooms, 1 staff live-in room and 2 restrooms in the facility. One of the three resident rooms was observed without screen window. No non skid mat was observed in the bathrooms. S1 installed non skid mats in both bathrooms before LPA finished the inspection. Room temperature was observed at 74 degree F, and hot water temperature was observed at 110 degree F. The temperature of refrigerator was observed at 40 degree F, and the temperature of the freezer was observed at 0 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. First aid box, and flash lights were observed in the facility. No night light was observed in the facility. S1 installed night lights before LPA finished inspection. The last time the facility conducted the emergency drill is 6/17/2024.
Continue on LIC809-C. Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: KB CARE HOME
FACILITY NUMBER: 435202293
VISIT DATE: 06/27/2024
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The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm system. S1 tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 06/03/2024. LPA toured the backyard, there was no obstruction to block the walkway. A storage room was observed in the backyard.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with S1. The reports were provided to S1 for signature. A copy of this report was provided to S1.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/28/2024 08:02 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 06/27/2024 at 04:34 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: KB CARE HOME
FACILITY NUMBER: 435202293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 in that one of the three resident bedrooms was observed without screen window which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Staff S1 stated to submit the plan of correction by the POC due date to install a good screen window for the resident bedroom.
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

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 that resident R1's appraisal/needs and service plan was completed on year 2020 and resident R2's appraisal/needs and service plan was completed on year 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Staff S1 stated to submit a plan of correction by the POC due date to complete residents' appraisal/needs and service plans annually.
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: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
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