435202414-12-26-2023-26-AS-LSAR-CYVM94-20231226082406

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202414
Report Date: 12/20/2023
Date Signed: 12/26/2023 08:24:36 AM

Document Has Been Signed on 12/26/2023 08:24 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME:	DURALIZA CARE HOME		FACILITY NUMBER:	435202414
ADMINISTRATOR:	AIDA D. PENDON		FACILITY TYPE:	740
ADDRESS:	1938 ENSIGN WAY		TELEPHONE:	(408) 923-1160
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95133
CAPACITY:	6	CENSUS: 6	DATE:	12/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Administrator Rhonald S Aranzaso		TIME COMPLETED:	06:30 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	On 12/20/23, Licensing Program Analysts (LPA) L. Salazar and LPA Doucette arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPAs were greeted by Staff, stated the purpose of the visit and was allowed entry into the facility. Administrator arrived to the facility a few minutes later. Staff provided a tour of the facility inside and out. Administrator on record is Rhonald S Aranzaso, Certificate #6023096740 Expires 01/2024. There are currently 6 residents in the home. The facility is a 5 bedroom / 2 bathroom home. No residents are receiving Hospice services or receiving Home Health care service. A sample of resident and staff files were reviewed and observed to have the required forms and training records. LPA toured the facility inside and out and observed the facility temperature read at 72 degrees F. Resident bedrooms were observed to have the required lighting/furnishings and are free from odor and passageway obstruction/fire hazards. Bathrooms were observed to have operational lights, running water, and non-slip floors. Hot water temperature tested at 148.4 degrees F. Facility turned down water heater in the presence of LPA's, which is measuring at 93.2 F. Facility will continue to check water heater to be in compliance. Required postings were observed for Non-discrimination LGBTQ-A+, Personal Rights of Residents in RCFE (87468.1 and 87468.2), facility's visitation policy and Complaint Poster. Cleaning supplies were observed to be locked in the garage . LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. Menus for the facility were observed. Carbon monoxide detectors were observed to be operational. Fire Extinguisher was observed with a service date of 06/22/23. First aid kits were observed to contain all required items. (Continued LIC 809-C)

SUPERVISOR'S NAME: Melinda Medina	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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
Lookup Error,
, CA

FACILITY NAME: DURALIZA CARE HOME	FACILITY NUMBER: 435202414
	VISIT DATE: 12/20/2023

NARRATIVE

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(Continued from 809)

Medications were observed to be in a locked cabinet in the kitchen. Quarterly Emergency Disaster Drill logs were observed. Last drill was on 12/16/23.

LPA is requesting the following documents be submitted to the Fresno CCL office by 01/05/2023: Designation of Facility Responsibility (LIC308), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance Emergency and Disaster Plan (LIC 610ES) Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020A), copy of current Surety Bond.

An exit interview was conducted with Administrator. A copy of this report, plans of correction and appeal rights were discussed and provided at the time of visit.

SUPERVISOR'S NAME: Melinda Medina	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/26/2023 08:24 AM - 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
Lookup Error,
, CA

FACILITY NAME: DURALIZA CARE HOME	FACILITY NUMBER: 435202414
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the common bathroom where the water temperature measured at 148.4 F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/21/2023
	Plan of Correction
1 2 3 4	Administrator has turned down the water heater and ran the water at the time of visit, bringing the water temp down immediately. Administrator will measure water temperature 2x daily, and document on a water temperature log. Administrator will scan proof that temperature log was created by POC date. Administrator will also send copies of temperature logs to LPA on 12/28/23 and 01/05/24. Logs will evidence the water temperature measures between 105 F to 120 F.

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: Melinda Medina	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

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