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Department of
SOCIAL SERVICES

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 HOMEFACILITY NUMBER:
435202583
ADMINISTRATOR/
DIRECTOR:		VU, KRISTINE ABLAOFACILITY TYPE:
740
ADDRESS:2934 JESSIE COURTTELEPHONE:
(408) 628-4702
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 3DATE:
11/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:28 AM
MET WITH:Michael VuTIME VISIT/
INSPECTION COMPLETED:
12:28 PM
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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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
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
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.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
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)
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Document Has Been Signed on 11/21/2024 04:43 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 11/14/2024 at 10:10 AM
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: JESSIE COURT CARE HOME
FACILITY NUMBER: 435202583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2024
Section Cited

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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 ...
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The requirement was not met as evidenced by:
Based on the records reviewed, Administrator did not send the incident report of resident R1 was sent to hospital within 7 days of the incident occurrence, this poses a potential health, safety or personal rights risk to persons in care.
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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 Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
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)
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