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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202540
Report Date: 12/23/2024
Date Signed: 12/23/2024 04:30:32 PM

Document Has Been Signed on 12/23/2024 04:30 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:AMY'S SENIOR CARE INCFACILITY NUMBER:
435202540
ADMINISTRATOR/
DIRECTOR:
MANN, AMARJEETFACILITY TYPE:
740
ADDRESS:701 N WHITE ROADTELEPHONE:
(408) 926-7308
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Amarjeet MannTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Amarjeet Mann.

Two staff and six residents were observed in facility.

LPA reviewed 3 resident files and 3 staff files.

License, Administrator Certificate, and personal rights posters were observed in the facility.

LPA toured the facility inside and out with ADM. LPA inspected living room, dinning area, kitchen. There are 3 restrooms, 1 staff live-in room, 6 resident single rooms in facility. Two days perishable foods and seven non perishable foods were observed sufficient. Room temperature was observed at 72 degree F, hot water temperature was observed at 119 degree F. Medication cabinet, Knife closet were observed locked. Dish cleaning product bottle was observed on the top of the sink in kitchen, ADM put dish cleaning product bottle in the cabinet under the sink in kitchen and locked it immediately. Fire extinguisher was serviced on 7/29/2024. The facility was equipped with smoke and carbon monoxide detectors. carbon monoxide detector was tested, and was working fine. First aid box was observed at the facility. Flash lights and night lights were observed in the facility. The last time the facility conducted the emergency drill was on 10/16/2024. ADM provided 3 residents' physician order/recommendation for using bed rails.

Front yard and backyard were inspected. Two storage rooms were observed at the back yard. There was no obstruction to block the walkways.

Deficiency noted issued today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
Romeo ManzanoTELEPHONE: (408) 277-1289
Chihhsien ChangTELEPHONE: (408) 904-9843
DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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Document Has Been Signed on 12/23/2024 04:30 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: AMY'S SENIOR CARE INC

FACILITY NUMBER: 435202540

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that 1 out of 3 resident's centrally stored medication forms was observed not matched with medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due date to ensure residents' centrally stored medication forms are matched with the medications. Administrator agreed to send staffing training log to CCL office.
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.
Romeo ManzanoTELEPHONE: (408) 277-1289
Chihhsien ChangTELEPHONE: (408) 904-9843

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024

LIC809 (FAS) - (06/04)
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