435202543-12-11-2024-26-AS-MMOR-DBUTS8-20241211135844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202543
Report Date: 12/11/2024
Date Signed: 12/11/2024 01:59:01 PM

Document Has Been Signed on 12/11/2024 01:59 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:	GRACE GARDEN RCFE		FACILITY NUMBER:	435202543
ADMINISTRATOR/ DIRECTOR:	FESSEHA, PATTI Y		FACILITY TYPE:	740
ADDRESS:	2463 GLEN EXETER WAY		TELEPHONE:	(408) 661-6623
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Administrator Patti Fesseha		TIME VISIT/ INSPECTION COMPLETED:	02:05 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) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Patti Fesseha. During the visit, LPA observed 5 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 115 degrees F in both resident bathrooms. While touring the home, LPA observed the family room, adjacent to bedroom #4. LPA observed the family room was being used as a bedroom. ADM stated she is having a resident stay there and did not notify the Department of the change of use of this room. (Photographs were taken). While touring the backyard, LPA observed a sliding screen door installed in bedroom #4 and the family room adjacent to bedroom #4. ADM stated stated these changes were done sometime in February 2024. LPA requested to review the facility fire/earthquake drill log. The facility's last drill was on September 31, 2024. LPA observed the fire drill for the fourth quarter had already been signed, for December 31, 2024. ADM stated it was a typo and the drill was conducted in December 1, 2024. LPA requested ADM conduct another drill for the month of December and send LPA documentation that the drill had taken place. Page 1 Out of 2.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

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 5

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: GRACE GARDEN RCFE	FACILITY NUMBER: 435202543
	VISIT DATE: 12/11/2024

NARRATIVE

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Fire extinguisher was serviced in February 1, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit

LPA reviewed facility records for 3 residents. Resident R1's physicians report dated June 14, 2022 and May 29, 2024 states R1 has a neurocognitive disorder. A review of R1's needs and services plan, dated February 8, 2023, states R1 has mild dementia. ADM stated she did review R1's May 29, 2024 physicians report.

LPA asked to review resident R3's care plan. ADM stated she has not created one. ADM stated she only has the pre-admission appraisal. LPA asked again if she has any documentation of the care plan for R3. ADM stated she has not done it.

LPA reviewed 3 staff records. LPA requested to review staff S1 and S2 health screening. ADM stated she has not done the health screenings for these two staff. LPA requested to review S1 and S2 and S3's education background and past experience. ADM stated she knows but has not documented it in the staff's files. LPA requested to review S1, S2 and S3's first aid training. (S2's first aid training is expired.) ADM stated the staff has not completed their first aid, but they are planning on completing the first aid training later this month.

LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 residents. LPA provided ADM with a flyer "Important updates to Dementia Care & Miscellaneous Changes, Effective January 1, 2025."

LPA requested a copy of the following documents:
1.LIC 500, Personnel Summary 2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources 4. Liability Insurance
5. Qualifications of Administrator (Certificate) 6. Copy of surety bond
7. Please review your facility program for updates (incorporating new laws and/or regulations)

Deficiencies cited during today's visit, see LIC809-D. Technical violations were cited. This report was reviewed with Administrator Patti Fesseha and a copy of the signed report was provided. Appeal rights were provided. Page 2 Out of 2. END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 12/11/2024 01:59 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: GRACE GARDEN RCFE	FACILITY NUMBER: 435202543
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA observed the family room, adjacent to bedroom #4 being used as a bedroom. LPA observed a sliding screen door installed in bedroom #4 and the family room adjacent to bedroom #4. These changes were not reflected on the facility's current sketch and fire clearance. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2024
	Plan of Correction
1 2 3 4	ADM stated she will send a request to Department to have the changes in the facility physical plant updated on the physical sketch and the facility fire cleareance. ADM stated she will send this request to the Department by POC date, December 18, 2024.

Section Cited

Personal Accommodations and Services

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & interview, the licensee did not comply with the section cited above. LPA observed the family room, adjacent to bedroom #4. LPA observed the family room was being used as a bedroom. ADM stated she is having a resident stay there and did not notify the Department of the change of use of this room. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2024
	Plan of Correction
1 2 3 4	ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the letter to LPA by POC date, December 18, 2024.

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 Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 12/11/2024 01:59 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: GRACE GARDEN RCFE	FACILITY NUMBER: 435202543
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview & record review, the licensee did not comply with the section cited above. LPA requested to review staff S1 and S2 health screening. ADM stated she has not done the health screenings for these two staff. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2024
	Plan of Correction
1 2 3 4	ADM stated she will get a health screening for staff S1 and S2. ADM stated she will send LPA a copy of the completed form by POC date, December 18, 2024.

Section Cited

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. LPA requested to review S1, S2 and S3's first aid training. (S2's first aid training is expired.) ADM stated the staff has not completed their first aid, but they are planning on completing the first aid training later this month. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2024
	Plan of Correction
1 2 3 4	ADM stated she will have staff S1-S3 sign up for first aid training. ADM stated she will send LPA documentation this has been done by POC date, December 18, 2024.

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 Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 12/11/2024 01:59 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: GRACE GARDEN RCFE	FACILITY NUMBER: 435202543
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview & record review, the licensee did not comply with the section cited above. LPA asked to review resident R3's care plan. ADM stated she has not created one. ADM stated she only has the pre-admission appraisal. LPA asked again if she has any documentation of the care plan for R3. ADM stated she has not done it. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2024
	Plan of Correction
1 2 3 4	ADM stated she will fill out a needs and services plan for resident R3. ADM stated she will send a copy of R3's care plan to LPA by POC date, December 18, 2024.

Section Cited

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Resident R1's physicians report dated June 14, 2022 and May 29, 2024 states R1 has a neurocognitive disorder. A review of R1's needs and services plan, dated February 8, 2023, states R1 has mild dementia. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2024
	Plan of Correction
1 2 3 4	ADM stated she will send a copy of an updated Needs and Services Plan for resident R1. ADM stated she will send a copy of the updated care plan to LPA by POC date, December 18, 2024.

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 Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5