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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202616
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:09:04 PM


Document Has Been Signed on 01/26/2023 03:09 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:KEENE KAREFACILITY NUMBER:
435202616
ADMINISTRATOR:GAMBOA, ABIGAILFACILITY TYPE:
740
ADDRESS:2488 GLEN ELM WAYTELEPHONE:
(408) 531-9678
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 5DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Administrator Abigail GamboaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai and LPA Manuel Monter conducted an unannounced annual inspection focusing on infection control. LPAs met with Licensee/Administrator Abigail Gamboa and Licensee Mayanne Tenorio. There are 5 clients at the facility and 5 staff including Administrator were observed.

During visit, LPAs toured the facility to include the 1 living room, 1 family room, 5 resident rooms, 2 bathrooms, kitchen, laundry area, dining area, garage and exterior. All fire exit routes are free and clear of obstruction. Toxins and sharp objects were secured. Medication stored in a locked cabinet.
Facility observed to have a designated central entry point to include a sign-in sheet and temperature check. Facility clean and disinfect twice daily and as often as needed. Bathrooms supplied with hygiene products and hand washing sign. Trash can with lid observed. LPAs observed a sufficient amount of Personal Protective Equipment (PPE). The following posters observed to include wash your hands, symptoms of COVID-19, importance of wearing a mask, and donning and doffing PPE.

LPAs observed 5 out of the 5 residents having a half-side rail attached to their beds. Per Administrator, 2 residents are under Hospice care. After record review for R1-R3, the facility does not have a written order for half-side rails in the resident's records. Administrator stated R1-R3 are not fall risk residents and they use the half-side rails for mobility.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

This report was reviewed with Licensee/Administrator Abigail Gamboa and Licensee Mayanne Tenorio and a copy of the report was provided. Appeal Rights was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2023 03:09 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: KEENE KARE
FACILITY NUMBER: 435202616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608(a)(3) Postural Supports. A written order from a physician indicating the need for the postural support shall be maintained in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 3 residents have half-side rails on their beds without a written order from a physician, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
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Administrator stated they will submit a written order from a physician for R1 and R2. Administrator will remove the bed with half side rails for R3 and resident will use a regular bed and submit a photo to LPA Rai. Administrator will submit a written plan on facility's policy and procedure on obtaining written order from physician for half-side rails by the POC date.
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: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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