435202411-1-30-2024-26-AS-CDOS-CZYRN5-20240130120946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202411
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:09:58 PM

Document Has Been Signed on 01/30/2024 12:09 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:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Avelina Pascua		TIME COMPLETED:	12:15 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 Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required 1-year inspection. LPA met with House Manager/Designated Administrator, Avelina Pascua. During visit, LPA toured the facility with the house manager to include the living room, dining room, kitchen, activity room, bathrooms, garage, resident bedrooms, and backyard. All fire exit routes were free and clear of obstruction. Carbon Monoxide detector present in the facility. Fire extinguisher last serviced on 01/10/2024. Facility temperature maintained at 78 degrees Fahrenheit. All staff present are fingerprint cleared and associated to the facility. Resident bedrooms observed well maintained with beds, clean linens, dressers, night stands, and adequate lighting. The facility has an approved exception request for resident (R3)'s postural supports. Bathrooms supplied with hygiene products, paper supples, and non-slid matts. Hot water temperature maintained at 112 degrees Fahrenheit in 2 out of 2 bathrooms. LPA reviewed 3 resident (R1 - R3) files to include an admission agreement, medical assessment, TB result, consent forms, emergency identification forms, safeguard personal property and valuables, and personal rights form. 3 out of 3 residents appraisal/needs and services plan were last updated in 2020. 2 out of 3 residents IPP was last updated in 2022. 1 out of 3 resident's file did not contain an IPP. Facility was advised. SEE LIC809-C.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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 4

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: 01/30/2024

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
26
27
28
29
30
31
32

LPA reviewed 3 staff (S1 - S3) files to include an updated 1st Aid certification, health screening, TB information, employee rights, and personnel record. The facility was unable to produce staffs annual training to include dementia care, postural supports, restricted health conditions, and hospice care. The last training was completed in year 2022. Facility was advised.

Facility's Emergency Disaster Plan was posted on the bulletin board located in the hallway and was dated in 2015 to include former staff members. LPA advised the house manager to update their emergency disaster plan. House Manager stated understanding. Facility has their facility sketch posted in a common area. Facility has extra flash lights and batteries. LPA observed the facility's first aid kit to be complete. Emergency drills are being conducted quarterly and the last drill was completed on 01/14/2024.

Facility's Infection Control Plan was last updated in 2022. LPA advised the facility to update their infection control plan annually to ensure accuracy. Facility has a sufficient amount of PPE supplies,

Posters and signs observed posted in common areas to include house rules, grievance, personal rights, complaint poster, ombudsman, and COVID-19 related resources.

LPA interviewed 3 staff members.

Documents were obtained to include the facility sketch and R3's admission agreement. LPA requested for the facility's certificate of liability insurance via email.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with House Manager/Designated Administrator Avelina Pascua and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/30/2024 12:09 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: KINGMAN CARE HOME LLC	FACILITY NUMBER: 435202411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not ensure staff were provided annual 20 hours of training to inlcude dementia care, postural supports, restricted health conditions, and hospice care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/06/2024
	Plan of Correction
1 2 3 4	Licensee will provide training to all the staff regarding the section cited above. Licensee will submit the training documentations to LPA Dolores by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/30/2024 12:09 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: KINGMAN CARE HOME LLC	FACILITY NUMBER: 435202411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not ensure to update residents appraisal/needs and services plan every 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/06/2024
	Plan of Correction
1 2 3 4	Licensee will update all resident's appraisal/needs and services plan. Licensee will submit the updated copies to LPA Dolores by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4