435202411-3-30-2023-26-AS-CDOS-CQEUZS-20230330160202

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202411
Report Date: 03/30/2023
Date Signed: 03/30/2023 04:02:15 PM

Document Has Been Signed on 03/30/2023 04:02 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:	KINGMAN CARE HOME LLC		FACILITY NUMBER:	435202411
ADMINISTRATOR:	ANTHONY CASIM		FACILITY TYPE:	740
ADDRESS:	1426 KINGMAN AVENUE		TELEPHONE:	(408) 945-9197
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY: 6		CENSUS: 6	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Avelina Pascua		TIME COMPLETED:	04:10 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 Analysts (LPAs) Christine Dolores and Tracy Pham arrived unannounced to conduct the facility's annual inspection. LPAs met with House Manager, Avelina Pascua. During visit, LPAs toured the facility to include the living room, kitchen, resident bedrooms, bathrooms, activity rooms, office, laundry room, garage, and backyard. Facility has a fire clearance approved for 6 non-ambulatory residents. All fire exit routes were free and clear of obstruction. Facility is equipped with ramps and hand-rails. Fireplace is screened. All sharp objects and chemicals observed locked. Facility observed well-kept with no foul odor, clean floors, tables, and counter tops. Residents bedrooms are equipped with proper furniture, lighting, and linens. Additional bedding and linens are available to the residents and observed clean. Bathrooms observed with grab bars, non-skid maters, hygiene supplies, toiletry, hand washing signs, and lidded trash bins. Facility kitchen is equipped with clean cups, plates, utensils, and cooking supplies. Hot water temperature was measured between 108.6 - 109.0 degrees Fahrenheit. LPAs observed at least 2 days worth of perishables and 7 days worth of non-perishables foods. Refrigerator temperature in the kitchen maintained at 37 degrees Fahrenheit. Freezer temperature in the kitchen maintained at 0 degrees Fahrenheit. Facility has a separate refrigerator/freezer for over stock food located in the garage. LPA Dolores advised to ensure the freezer has a thermometer. Fire extinguisher was last serviced on 01/18/2023. LPAs observed facility has an operating carbon monoxide detector. SEE LIC809-C.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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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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: KINGMAN CARE HOME LLC	FACILITY NUMBER: 435202411
	VISIT DATE: 03/30/2023

NARRATIVE

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Posters observed to include resident personal rights, grievance, house rules, ombudsman, if you see something say something, facility sketch, emergency disaster plan, sample menu, sample activities, visitation, and COVID-19 related posters. LPAs observed the emergency disaster plan posted was from 2015. LPAs advised to update the emergency disaster plan.

LPAs reviewed 6 out of 6 resident files to include their medical assessment, needs and services plan and/or IPP, admission agreement, consent forms, weight records, immunization record, emergency information, centrally stored medication records, safeguard of personal property, and P&I money. Facility was advised to review 2 out of 6 residents P&I money as the balance was over the actual amount on the record. House Manager stated understanding.

LPAs reviewed 3 staff files to include their first aid certification, health screening, staff training, and background clearance. All staff present are fingerprint cleared and associated to the facility.

LPAs interviewed 6 out of 6 residents and 3 out of 3 staff members.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with House Manager, Avelina Pascua and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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