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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202293
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:09:51 PM

Document Has Been Signed on 11/30/2023 12:09 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:KB CARE HOMEFACILITY NUMBER:
435202293
ADMINISTRATOR:KAITLYN BROWNELLFACILITY TYPE:
735
ADDRESS:1948 SEABEE PLACETELEPHONE:
(408) 823-6734
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 5DATE:
11/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kaitlyn BrownellTIME COMPLETED:
12:15 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) Christine Dolores arrived unannounced to originally deliver complaint investigation findings. During visit, a case management - deficiencies visit was conducted based on violations observed. Administrator (ADM), Kaitlyn Brownell sat outside the facility and was unable to enter the facility due to a sickness. ADM provided consent to staff (S1) to sign the reports. LPA communicated with ADM via telephone.

There were no residents present inside the facility during visit. Staff (S1) states the residents are at the day program. LPA toured the facility with staff (S1) to include the living room, kitchen, dining room, garage, resident bedrooms, and staff room. LPA observed the facility's backyard. During tour of the garage, LPA observed a mattress, linens, comforter, and personal items that were surrounded by cardboard boxes, dressers, and shelves. Staff (S2) was interviewed and states to be a live-in staff. S2 states to sleep in the staff bedroom located inside the facility but sleeps in the garage during break-time. LPA observed S2 is not fingerprint cleared per the Department's background check system, Guardian. ADM was unable to provide proof that S2 was cleared by the Department prior to employment. ADM states S2 started work in the facility a "couple weeks ago", however, based on review of S2's files documents were dated from October 20, 2023. S2 was asked to leave the facility. ADM was informed that S2 cannot continue to live or work in the facility until S2 receives a fingerprint clearance from the Department. A copy of S2's application and LIC9182 was obtained during visit.

Deficiencies were cited per California Code of Regulations, Title 22. A plan of correction (POC) was developed with ADM. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S2) working and residing at the facility without fingerprint clearance. Please see LIC 421BG. This report was reviewed with Administrator, Kaitlyn Brownell over the telephone. ADM provided verbal consent to allow staff (S1) to sign the report. A copy of the report and appeal rights were provided during visit.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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 2
Document Has Been Signed on 11/30/2023 12:09 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Christine Dolores On 11/30/2023 at 10:55 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: KB CARE HOME
FACILITY NUMBER: 435202293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
12/01/2023
Section Cited
CCR
80019(e)(2)

1
2
3
4
5
6
7
(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 or... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee asked staff (S2) to leave the facility. Licensee will have staff re-fingerprinted. Licensee will submit a statement of understanding of section 80019(e)(2) by POC due date.
8
9
10
11
12
13
14
Based on interview, record review, and observation the licensee did not ensure staff (S2) obtained a fingerprint clearance prior to working and residing in the facility which poses an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
ADM was informed the POC and/or extension request is due by 12/01/2023.
Type A
12/01/2023
Section Cited
CCR85087(a)(3)(A)

1
2
3
4
5
6
7
(a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements: (3) No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee immediately removed the personal items and bedding during visit. POC cleared during visit.
8
9
10
11
12
13
14
Based on interview, record review, and observation the facility's garage was being used a sleeping quarters for staff which poses an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


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