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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202469
Report Date: 10/16/2024
Date Signed: 10/16/2024 12:45:56 PM

Document Has Been Signed on 10/16/2024 12:45 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:DESTA RESIDENTIAL CARE FACILITYFACILITY NUMBER:
435202469
ADMINISTRATOR/
DIRECTOR:		DAISY ESTOESTAFACILITY TYPE:
735
ADDRESS:2012 AUTUMNTREE CT.TELEPHONE:
(408) 930-7565
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 6CENSUS: 4DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Daisy EstoestaTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcela Yanez and Christine Dolores conducted an unannounced Required 1 Year visit and met with Daisy Estoesta, Administrator/Licensee.

During visit, LPAs toured the facility inside and out with staff. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and refrigerator temperature measured with thermometer at 39.5 degrees F and freezer measured with thermometer at 0 degrees F.

LPAs observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days.

LPA toured four resident bedrooms. Each resident bedroom had available bedding and clothing storage areas as well as functioning lights. LPAs observed full length bed rail in bedroom #3 picture was taken of full length using LPA Yanez state provided phone. LPAs reviewed resident record and no doctor order was found for the full length bed rails. The review of residents IPP and Needs and Services Plan did not indicate the need for full length bed rails. Administrator stated the full length bed rails is for behavior to help resident fall asleep.

Administrator tested the smoke detectors in the hallway and found the smoke detector to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had available soap and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 123.4 degrees F in bathroom #1 and 124.8 degrees F in bathroom #2. Administrator was advised of Ttle 22 regulation that the water temperature shall be maintained between 105 degrees F and not more then 120 degrees F.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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: DESTA RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 435202469
VISIT DATE: 10/16/2024
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LPA toured the outside area and found the exits to be clear of obstructions. LPAs observed a shed that is for facility storage.
LPA observed fire extinguisher was last serviced on 05/21/2024 LPA reviewed Fire and Earthquake log was last conducted on 10/05/2024

LPA reviewed resident records for 3 residents and 3 staff records and found them to be complete. LPAs reviewed 3 residents centrally stored medication record and P&I and found them to be complete.

Deficiencies were cited as per California Code of Regulations Title 22. Advisory note provided.This report was reviewed with Daisy Estoesta and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 12:45 PM - It Cannot Be Edited


Created By: Marcela Yanez On 10/16/2024 at 12:01 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: DESTA RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 435202469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above for 1 resident who uses full length bed rails in which the need for the full length bed rails was not included in the Needs and Services Plan and IPP which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Licensee will submit a plan of action for moving forward to ensure the Needs and Services Plan to be accurate to include all the residents needs. Licensee will submit plan of correction via email to LPA Yanez by the due date 10/23/2024.
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 Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/16/2024 12:45 PM - It Cannot Be Edited


Created By: Marcela Yanez On 10/16/2024 at 12:09 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: DESTA RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 435202469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(8)(E)(1)
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (8) Not to be placed in any restraining device. Postural supports may be used under the following conditions:
(E) Under no circumstances shall postural supports include tying of, or depriving or limiting the use of, a client's hands or feet 1. …Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by using full length bed rails for 1 resident without a physicians order or approval from the department which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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During visit Administrator removed full length bed rails with the permission of resident conservator and Administrator will provide a letter with the decision to remove full length bed rails, Administrator will provide a letter of understanding after reviewing Title 22 regulation sectioned above. Administrator will provide the POC to LPA Yanez via email by 10/17/2024
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 Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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