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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202583
Report Date: 02/05/2025
Date Signed: 02/05/2025 04:20:10 PM

Document Has Been Signed on 02/05/2025 04:20 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:
02/05/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:MIchael VuTIME VISIT/
INSPECTION COMPLETED:
12:30 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 visit and met with Co-licensee Michael Vu (Co-LCN).

The purpose of today's visit is to follow up with the incident report that Community Care Licensing (CCL) office received on 01/27/2025. On 01/24/2025, around 11:00AM, resident R1 was found missing in facility. R1 was last seen in his/her room on 01/24/2025, around 10:00AM. Facility staff S1 and S2 checked the facility inside and out, but were unable to find R1. S1 went out to search for R1 in the neighborhood but was unable to find R1. S2 called Licensee to notify the incident. Licensee called 911 at 11:15AM.

LPA interviewed staff S1. S1 stated on 1/24/2025, resident R1 was seen at his/her room around 10:00AM. S1 stated at 11:00AM, he/she checked R1 again but was unable to find R1. S1 stated he/she and staff S2 checked the facility inside and out but were unable to find R1. S1 stated he/she went out to search for R1 in the neighborhood but was unable to find R1.

LPA interviewed staff S2. S2 stated on 1/24/2025, between 10:00AM to 11:00AM, he/she was helping other residents in resident bedrooms. S2 stated he/she was notified by S1 that R1 was missing. S2 stated he/she and S1 searched for R1 but were unable to find R1. S2 stated he/she called R1' family and licensee.

LPA interviewed Co-licensee (Co-LCN). Co-LCN stated on 1/24/2025 around 3:00PM police officers notified the facility that they found R1 at Campbell park. R1 was brought back to the facility around 3:45PM by police officers. The distance between the facility and Campbell Park is around 1.7 miles per google map. Co-LCN stated R1 was brought back to the facility without injury. Co-LCN stated R1 has dementia. S1 stated R1 is fine and normal after returning to the facility. Co-LCN stated R1 is unable to remember what happened about the incident.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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: 02/05/2025
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
26
27
28
29
30
31
32
Based on the reviewed of R1's physician report dated on 11/09/2024, R1 has dementia. R1 has wandering behavior and is unable to leave facility unassisted.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D.
An immediate civil penalty of $500.00 is being assessed today for violation the absence of supervision.

Exit interviewed was conducted with Co-LCN. The report was provided to HM for review and signature. Appeal rights was provided. A copy of the report was provide to Co-LCN.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 02/05/2025 04:20 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 02/05/2025 at 11:16 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: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2025
Section Cited
ILS
87468.1(a)(2)

1
2
3
4
5
6
7
87468.1 Personal Rights (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated to submit a plan of correction by the POC due date to provide the training to staff to provide care and supervision to meet residents' needs and to provide the staff training log.
8
9
10
11
12
13
14
Based on interview and record review, Licensee did not provide the necessary care and supervision to meet R1's care needs, which resulted in R1's elopement from the facility on 1/24/2025, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3