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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202297
Report Date: 04/09/2024
Date Signed: 04/09/2024 04:12:59 PM

Document Has Been Signed on 04/09/2024 04:12 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:SKYE CARE HOME INC.FACILITY NUMBER:
435202297
ADMINISTRATOR/
DIRECTOR:		ROSE R. ABADAMFACILITY TYPE:
735
ADDRESS:2987 POSTWOOD DRIVETELEPHONE:
(408) 493-5136
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Rose AbadamTIME VISIT/
INSPECTION COMPLETED:
11:58 AM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Rose Abadam.

LPA observed 2 staff and 1 resident in the facility. The other 3 residents went to day program. LPA checked 2 resident record files and 2 staff record files.

LPA toured the facility inside and out with ADM. Facility license, Administrator Certificate, and Personal Rights posters were observed posted at the facility.

Living room, kitchen, dinning room and two restrooms were inspected. 3 shared resident bedrooms, 2 restrooms, laundry room, and garage were inspected. 1 staff room was observed in the facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet were observed locked. Dish cleaning product cabinet was observed unlocked. ADM add a lock and locked the dish cleaning product cabinet before LPA finished the inspection visit. Room temperature was at 70 degree F, and hot water temperature was at 117 degree F in facility. First Aid box, flash lights and night lights were observed in the facility. The last time the facility conducted the emergency drill was on 3/5/2024.

Fire extinguisher was serviced on 03/22/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by staff, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. One storage room was observed in the backyard.

Deficiencies noted today See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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 5
Document Has Been Signed on 04/09/2024 04:12 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 04/09/2024 at 10:37 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: SKYE CARE HOME INC.
FACILITY NUMBER: 435202297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 the dish washing product cabinet was observed unlocked which poses an immediate health, safety risk to persons in care.
ADM added a lock and locked the dish washing product cabinet before LPA finished the visit.
POC Due Date: 04/10/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to lock the dish washing product cabinet.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/09/2024 04:12 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 04/09/2024 at 10:37 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: SKYE CARE HOME INC.
FACILITY NUMBER: 435202297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

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 one resident's P & I money transaction log was observed not maintained up to date which poses/posed a potential personal rights risk to persons in care.
ADM updated the resident P & I money transaction log before LPA finished the visit.
POC Due Date: 04/16/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to maintain resident P & I money transaction log up to date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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