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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202309
Report Date: 06/17/2024
Date Signed: 06/17/2024 04:40:02 PM

Document Has Been Signed on 06/17/2024 04:40 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:HELPING HANDS RESIDENTIAL CARE HOME 2FACILITY NUMBER:
435202309
ADMINISTRATOR/
DIRECTOR:		JANESSA FLORESFACILITY TYPE:
735
ADDRESS:349 SPRING VALLEY LN.TELEPHONE:
(408) 956-8596
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 4CENSUS: 4DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:48 PM
MET WITH:Administrator Janessa FloresTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Janessa Flores. During the visit, LPA observed 4 residents and 2 staff.

LPA toured the facility inside out with Staff S1 which included the Living room, kitchen, dining room, 3 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 116 degrees F in resident bathrooms.

Fire extinguisher was serviced in February 8, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on May 14, 2024.

LPA reviewed 4 resident medications and centrally stored medication records. While reviewing resident R3's medication records, LPA observed medication #1 had an extra medication tablet that was not administered on the 7th of June. (Photographs were taken.). LPA reviewed the Medication administration Record, which stated the medication had been given. ADM stated the pill wasn't popped out completely and given to the resident. A review of R3's physicians report states R3 cannot administer his/her own medications.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: HELPING HANDS RESIDENTIAL CARE HOME 2
FACILITY NUMBER: 435202309
VISIT DATE: 06/17/2024
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LPA reviewed facility records for 3 staff and 4 residents. While reviewing R4's records, LPA observed R4's physicians report was dated July 19, 2012. Resident R4 is above 60 years old. ADM stated she does not have an updated physician's report for R4. LPA reviewed 4 resident P&I records.

LPA conducted interviews with 1 staff and 2 residents.

LPA requested a copy of the following documents to be sent to the Department by June 24, 2024.
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. LIC200, please update (i.e., new phone numbers etc), if necessary.
6. Qualifications of Administrator (Certificate)
7. Please review your facility program for updates (incorporating new laws and/or regulations)
8. Please submit copy of surety bond

Deficiencies are being cited during today's visit, see LIC809-D. This report was reviewed with Administrator Janessa Flores and a copy of the signed report was provided. Appeal Rights were provided.

END OF REPORT

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2024 04:40 PM - It Cannot Be Edited


Created By: Manuel Monter On 06/17/2024 at 04:16 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: HELPING HANDS RESIDENTIAL CARE HOME 2
FACILITY NUMBER: 435202309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above. R4's physicians report is dated July 19, 2012. Resident R4 is above 60 years old. ADM stated she does not have an updated physician's report for R4. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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3
4
ADM stated she will schedule an appointment for R4. ADM stated she will send LPA a copy of R4's updated physicians report. ADM stated she will also send a letter of understanding regrading the regulation. ADM stated she will send the plan of corrections by POC date, June 24, 2024.
Type B
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. R3's medication #1 had an extra medication tablet that was not administered on the 7th of June. ADM stated the pill wasn't popped out completely and given to the resident. R3's physicians report states R3 cannot administer his/her own medications. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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ADM stated she will conduct a medication training with staff. ADM stated she will send documentation of the training that took place to LPA by POC date June 24, 2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


LIC809 (FAS) - (06/04)
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