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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202392
Report Date: 02/14/2024
Date Signed: 02/14/2024 05:04:02 PM


Document Has Been Signed on 02/14/2024 05:04 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:EVONNE'S RESIDENTIAL CARE HOME #1FACILITY NUMBER:
435202392
ADMINISTRATOR:PHILOMENA AGBONTAENFACILITY TYPE:
740
ADDRESS:2719 PENITENCIA CREEK RD.TELEPHONE:
(408) 661-5746
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:6CENSUS: 7DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator Philomena AgbontaenTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Philomena Agbontaen. During the visit, LPA observed 7 residents and 2 staff.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 5 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 110 degrees F in both resident bathrooms.

Fire extinguisher was serviced in March 13, 2023. 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 September 2, 2023.

LPA reviewed facility records for 3 staff. LPA reviewed facility records for 3 residents. LPA reviewed R1's facility file. R1's physicians report states R1 has dementia. R1's most current physicians report is dated September 6, 2022. ADM stated the physicians report has not been updated. LPA requested to review residents weight record log. ADM stated she doesn't have a log for the residents weights. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff (S1 to S2) and 2 residents (R1-R2).

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Philomena Agbontaen and a copy of the signed report was provided. Appeal rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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


Document Has Been Signed on 02/14/2024 05:04 PM - It Cannot Be Edited

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: EVONNE'S RESIDENTIAL CARE HOME #1
FACILITY NUMBER: 435202392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review residents weight record log. ADM stated she doesn't have a log for the residents weights. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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ADM stated she will send a plan of action on how the facility will maintian a weight record log for the residents. ADM stated she will send plan of action, by POC date, 02/21/2024.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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. The facility's last drill was on September 2, 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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ADM stated she will conduct a fire/earthquake drill and send documentation that a drill has taken place to LPA by POC date, 02/21/2024.
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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/14/2024 05:04 PM - It Cannot Be Edited

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: EVONNE'S RESIDENTIAL CARE HOME #1
FACILITY NUMBER: 435202392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

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. LPA reviewed R1's facility file. R1's physicians report states R1 has dementia. R1's most current physicians report is dated September 6, 2022. ADM confirmed the physicians report had not been updated. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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ADM stated she will send plan of action on how the facility will ensure Each resident with dementia shall have an annual medical assessment and a reappraisal done at least annually. ADM stated she will send plan of action to LPA by POC date, 02/21/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3