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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202502
Report Date: 01/27/2024
Date Signed: 01/27/2024 03:11:25 PM

Document Has Been Signed on 01/27/2024 03:11 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:HELPING HANDS RESIDENTIAL CARE HOME 3FACILITY NUMBER:
435202502
ADMINISTRATOR:JANESSA FLORESFACILITY TYPE:
735
ADDRESS:3318 DIAS DRIVETELEPHONE:
(408) 239-0916
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Janessa Flores and Licensee Rowena CalingTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Janessa Flores and Licensee (LCS) Rowena Caling. LPA Rai observed 2 staff and 5 residents at the facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas.

LPA Rai toured the resident bedrooms. 4 out of 4 resident bedrooms had available bedding, drawers, and functioning lights.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 111.2F - 112.6F. The water temperature in the kitchen sink was 111.2F.

Fire extinguisher was observed and bought new on 2/11/2023. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 01/24/2024.

LPA Rai reviewed facility records for 2 staff and 3 residents. LPA Rai observed 1 out of 3 resident files did not contain a signed consent form and Personal Rights form. LPA Rai reviewed resident medications and central stored medication records.

Deficiencies were cited per California Code of Regulations, Title 22, see LIC 809-D. This report was reviewed with Administrator (ADM) Janessa Flores and Licensee (LCS) Rowena Caling. A copy of the report and Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024
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 2
Document Has Been Signed on 01/27/2024 03:11 PM - It Cannot Be Edited


Created By: Simranjit Rai On 01/27/2024 at 02:43 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: HELPING HANDS RESIDENTIAL CARE HOME 3
FACILITY NUMBER: 435202502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(h)(4)
80075 Health Related Services (h)(4) It is recommended that the licensee obtain consent forms to permit the authorization of medical care.

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 in 1 out of 3 resident files did not contain a signed consent form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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Licensee and Administrator stated to submit a plan of action to understand regulations and ensure resident's files are complete by POC due date. Licensee And Adminstrator agreed and understood.
Type B
Section Cited
CCR
80072(a)(4)
80072 Personal Rights (a)(4) To be informed, and to have his/her authorized representative, if any, informed, by the licensee of the provisions of law regarding complaints...

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 in 1 out of 3 resident files did not contain a signed Personal Rights form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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Licensee and Administrator stated to submit a plan of action to understand regulations and ensure resident's files are complete. Licensee And Adminstrator agreed and understood.
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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024


LIC809 (FAS) - (06/04)
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