435202583-11-21-2024-26-AS-CCHG-DB92V4-20241121164315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202583
Report Date: 11/21/2024
Date Signed: 11/21/2024 04:43:26 PM

Document Has Been Signed on 11/21/2024 04:43 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:	JESSIE COURT CARE HOME		FACILITY NUMBER:	435202583
ADMINISTRATOR/ DIRECTOR:	VU, KRISTINE ABLAO		FACILITY TYPE:	740
ADDRESS:	2934 JESSIE COURT		TELEPHONE:	(408) 628-4702
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	11/21/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:28 AM
MET WITH:	Michael Vu		TIME VISIT/ INSPECTION COMPLETED:	12:28 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) Steve Chang Conducted an unannounced Case Management - Incident visit and met with Administrator (ADM) Michael Vu. On 11/07/2024, the Department received a death report of resident R1 which stating R1 was sent to hospital on 10/29/2024 due to left shoulder and abdominal pain. R1 died on 10/30/2024, around 2:00AM, facility is waiting for the information of R1's cause of death. On 11/08/2024, the Department received an updated death report of R1 with R1's cause of death. On 11/08/2024, the Department received an updated death report of R1 with description of R1's condition before R1 was sent to hospital on 10/29/2024 morning, and R1's physician report, Appraisal/Needs and Service Plan, Activities for Daily Living Questionnaire for MD review form, and Identification and Emergency Information Form. On 11/21/2024, LPA interviewed staff S1. S1 stated he/she received Colostomy training from Registered Nurse, the licensee to provide Colostomy care to resident R1. S1 stated Licensee and another staff S3 also provide Colostomy care to R1. S1 stated S3 also received Colostomy training from Register Nurse, the licensee. S1 stated R1 was able to feed self. R1 was able to comb self. S1 stated R1 was able to walk with walker or wheelchair. S1 stated he/she and S3 conducted bed bath for R1. LPA interviewed staff S2. S2 stated he/she did not provide Colostomy care to R1. S2 stated he/she cooks meals. Continue on LIC809-C. Page 1 of 2.

Romeo Manzano	TELEPHONE: (408) 277-1289
Chihhsien Chang	TELEPHONE: (408) 904-9843
	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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 3

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: JESSIE COURT CARE HOME	FACILITY NUMBER: 435202583
	VISIT DATE: 11/21/2024

NARRATIVE

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LPA interviewed Licensee (LCN) on the phone. LCN confirmed he/she provides Colostomy training to S1 and S2 two times per month. LCN stated he/she checked R1's Colostomy bag regularly to make sure it is clean. LCN confirmed he/she also provided Colostomy care to resident R1.

LPA interviewed ADM. ADM stated R1 was under restricted health condition for Colostomy. ADM stated the facility is compliance with the regulation. ADM stated staff S1 and S3 received the Colostomy training from registered nurse. ADM stated S1, S3 and the registered nurse provided Colostomy care to R1. ADM provided a copy the facility Colostomy training materials. ADM provided the twice per month Colostomy training log for S1 and S3.

Checked LPA's email log with the facility Administrator(ADM), an email from ADM on 10/30/2024 stating resident R1 was sent to hospital due to shoulder pain on 10/29/2024, and the facility will send an official incident report.

Based on the review of the incident reports that the facility sent to CCL office, there is no written incident report regarding R1 was sent to hospital.

Based on the review of R1's physician report and Appraisal/Needs and Service Plan, R1 is non ambulatory but is not bedridden. Based on the review of the facility fire clearance records, the facility has capacity of 6 non ambulatory residents and capability of 1 bedridden resident.

Based on the review of R1's physician report and Appraisal/Needs and Service Plan, R1 used colostomy bag which is restricted health conditions.

For today's visit, deficiency noted, citation was issued due to the facility did not send a written incident report of resident R1 was sent to hospital to CCL office within 7 days. See LIC809-D.

Exit interview was conducted with Administrator (ADM). This report was provided to ADM for review and signature. A copy of the reports was provided to ADM.

Page 2 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 11/21/2024 04:43 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: JESSIE COURT CARE HOME	FACILITY NUMBER: 435202583
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, (1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence ...(D)Any incident which threatens the welfare, safety or health of any resident ...
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 11/28/2024
	Plan of Correction
1 2 3 4	Administrator stated to read the regulation and send plan of correction by the POC due date to ensure the facility to send incident report to CCL office in timely manner.

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.

Romeo Manzano	TELEPHONE: (408) 277-1289
Chihhsien Chang	TELEPHONE: (408) 904-9843
	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3