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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202293
Report Date: 04/17/2024
Date Signed: 04/17/2024 11:22:55 AM

Document Has Been Signed on 04/17/2024 11:22 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
CENTRAL COAST CR/RES, 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: 5DATE:
04/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Kaitlyn BrownellTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Manuel Monter arrived unannounced to conduct a case management – deficiencies visit due to a violation found during a complaint investigation for control number 26-AS-20230619164800. LPAs met with Administrator, Kaitlyn Brownell.

During the complaint investigation, it was found that the Administrator had purchased resident (R1) a new mattress using R1’s cash resources also known as P&I money. Based on interview with the Administrator, the facility provides mattresses during new residents admission. R1 already had a mattress that was purchased by the facility, however, the Administrator purchased R1 a new mattress using R1's P&I money because R1's P&I money was reaching the maximum amount. The conversation regarding the purchase of a new mattress was discussed during a meeting. See Complaint control number 26-AS-20230619164800 for additional information. The new mattress that was purchased was described to be a hybrid 14" plush mattress.

The review of R1’s Admission Agreement states the facility’s basic general services includes a “comfortable and suitable bed including fresh linen weekly or more often…”.
Based on record review, on 04/29/2023 the facility documented the purchase of the mattress on R1’s P&I log.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Administrator, Kaitlyn Brownell and 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: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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 04/17/2024 11:22 AM - It Cannot Be Edited


Created By: Christine Dolores On 04/17/2024 at 08:36 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: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/24/2024
Section Cited
CCR
80026(f)

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(f) The licensee or employee of a licensee shall not make expenditures from clients' cash resources for any basic services in these regulations, or for any basic services identified in a contract/admission agreement between the client and the licensee. This requirement is not met as evidenced by:
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Licensee will acknowledge the Title 22 Section 80026(f) and will submit the acknowledgement in writing to the Department by POC due date.
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Based on interview, record review and observation the licensee had purchased resident (R1) a new mattress using R1's P&I money, which is a basic service item listed on the admission agreeement, which poses an potential health, safety, and personal rights risk to persons in care.
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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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
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