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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202583
Report Date: 10/25/2023
Date Signed: 10/26/2023 08:04:53 AM


Document Has Been Signed on 10/26/2023 08:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:JESSIE COURT CARE HOMEFACILITY NUMBER:
435202583
ADMINISTRATOR:VU, KRISTINE ABLAOFACILITY TYPE:
740
ADDRESS:2934 JESSIE COURTTELEPHONE:
(408) 628-4702
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:6CENSUS: 5DATE:
10/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Michael VuTIME COMPLETED:
11:18 AM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Michael Vu.

LPA checked 5 resident files and 3 staff files.

LPA toured the facility with HM. License, Administrator Certificate and Personal right posters were observed in the facility. There are 2 staff live-in rooms, 5 resident rooms, and 3 restrooms in the facility. Grabbing bars and Non skid pads were observed in the bathrooms. 3 staff and 5 residents were observed in the facility. LPA toured the kitchen, dining room, family room, laundry room and living room. The screens of windows in 3 bedrooms were observed not in good repair. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The room temperature was 70 degree F, and the hot water temperature was 108 degree F. The temperature of the refrigerator was measured at 40 degree F, and the temperature of freezer was measured at 0 degree F. Medication cabinet was observed locked. Knives cabinet was observed locked. Cleaning chemical products cabinet under the sink were observed unlocked. Fire extinguisher was serviced on 05/18/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, and were working fine. First aid box, flash light for emergency, audio door alarm for the main entrance and night light were observed in the facility.

LPA toured backyard with HM. No obstacles were observed blocked the walkway in the backyard. Some stuff were stocked at the backyard, HM stated the facility is going to clean it up. One storage room was observed at the backyard. A swimming pool was observed locked at the back yard. The facility had emergency and fire drill on 10/01/2023.

Deficiencies were noted today. See LIC809-D. Exit interview was conducted with HM. The report was provided to HM for signature. A copy of the report was provided to HM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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 3


Document Has Been Signed on 10/26/2023 08:04 AM - 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: JESSIE COURT CARE HOME
FACILITY NUMBER: 435202583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the cabinet under the sink in kitchen was observed unlocked, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Licensee stated to submit a plan of correction by the POC due date to add a new lock for the cabinet under the sink where the detergents were stored.
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 ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/26/2023 08:04 AM - 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: JESSIE COURT CARE HOME
FACILITY NUMBER: 435202583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 3 window screens were observed not in good repair, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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Licensee stated to submit a plan of correction by the POC due date to fix the 3 window screens of the bedrooms.
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 ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3