<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202567
Report Date: 09/04/2024
Date Signed: 09/09/2024 04:58:50 PM

Document Has Been Signed on 09/09/2024 04:58 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:SUCCESS RCF 1FACILITY NUMBER:
435202567
ADMINISTRATOR/
DIRECTOR:		AMAS, PRINCE-STANLEYFACILITY TYPE:
735
ADDRESS:64/68 SOUTH 10TH STREETTELEPHONE:
(408) 293-8166
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 32CENSUS: 30DATE:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Prince-Stanley AmasTIME VISIT/
INSPECTION COMPLETED:
02:45 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) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Prince-Stanley Amas.

During visit, LPA toured the facility inside and out. LPA toured the facility kitchen and dinning area. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. The first aid kit was reviewed and found to be complete.

LPA toured 12 out of 12 bedrooms in the 68 South 10th Street building and 20 out of 20 bedrooms in the 64 South 10th Street building. Each bedroom had working lights and available bedding and clothing storage areas. LPA Marrufo toured 3 out of 3 resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks were 118 F, 108 F, and 111 F. LPA toured the outside area and found the exits to be clear of obstructions. The smoke detector system was tested during visit and found to function properly when tested. LPA tested 2 out of 2 carbon monoxide detectors and found them to function properly when tested.

LPA reviewed the Centrally Stored Medication and Destruction Records (CSMDRs) and resident records for 5 residents. All 5 reviewed CSMDRs were found to be complete. Resident R1 was missing a Consent Form, Safeguard for Property and Valuables form, and LIC613 Resident Rights form. R2 was missing a Consent Form, Appraisal/Needs and Services Plan, Safeguard for Property and Valuables form, and LIC613 Resident Rights form. The other 3 reviewed resident records were found to be complete. 1 out of 1 resident Personal and Incidental Money Log was reviewed and found to be balanced. LPA reviewed 5 staff records and found them to be complete.

A deficiency was cited as per California Code of Regulations Title 22. This report was reviewed with ADM Prince-Stanley Amas and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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 09/09/2024 04:58 PM - It Cannot Be Edited


Created By: David Marrufo On 09/04/2024 at 02:09 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: SUCCESS RCF 1
FACILITY NUMBER: 435202567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records 80070 (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Licensee did not ensure that 2 out of 5 reviewed resident records were complete. Resident R1 was missing a Consent Form, Safeguard for Property and Valuables form, and LIC613 Resident Rights form. R2 was missing a Consent Form, Appraisal/Needs and Services Plan, Safeguard for Property and Valuables form, and LIC613 Resident Rights form, which poses a potential safety risk to residents in care.
POC Due Date: 09/11/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit copies of the records missing from residents R1 and R2 to CCL by POC date and to complete an audit of all resident records to ensure that no other resident records are missing. Then, Licensee shall submit a statement of completion to CCL by POC date stating all resident records have been audited and are complete.
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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2