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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202616
Report Date:
01/25/2024
Date Signed:
01/25/2024 05:51:58 PM
Document Has Been Signed on
01/25/2024 05:51 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 KARE
FACILITY NUMBER:
435202616
ADMINISTRATOR:
GAMBOA, ABIGAIL
FACILITY TYPE:
740
ADDRESS:
2488 GLEN ELM WAY
TELEPHONE:
(408) 531-9678
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95148
CAPACITY:
6
CENSUS:
6
DATE:
01/25/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:30 PM
MET WITH:
Abigail Gamboa
TIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Abigail Gamboa.
During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed the kitchen area, and observed a locked cabinet for sharp objects. LPA Marrufo observed a complete first aid kit. LPA Marrufo observed a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days.
LPA Marrufo toured two out of two resident bathrooms and observed functioning lights and available paper towels and soap. The water temperature in the bathroom sinks were 118 F and 119 F. LPA Marrufo toured 5 out of 5 resident bedrooms and observed each bedroom had working lights and available bedding and furniture. LPA tested the facility carbon monoxide detector and it functioned properly when tested. LPA Marrufo tested 7 facility smoke detectors and 3 did not function properly when tested. LPA toured the outside area and 1 out of 2 outside gate exits was not able to be opened during visit.
LPA Marrufo reviewed resident records and found the following records were missing from some of the resident files: Safeguard of Property and Valuables and Consent Form were missing from the records of residents R1-R4 and R6. LIC613 Personal Rights were missing from the records of R1 and R6. LPA Marrufo reviewed the facility staff records and observed the following records to be missing: LIC9052 Employee Rights form was missing from staff S1, S2, S4, and S6. S4 was also missing LIC503 Health Screening form and S6 was missing LIC501 Personnel Record and LIC508 Criminal Record Statement. The most recent entry in the Emergency Disaster Drill Log was from 01/06/2023.
An Advisory Note was issued. See LIC9102 for more information. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. This report was reviewed with Abigail Gamboa and a copy of the report was provided.
SUPERVISOR'S NAME:
Sarah Yip
TELEPHONE:
(408) 324-2131
LICENSING EVALUATOR NAME:
David Marrufo
TELEPHONE:
(650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE:
01/25/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/25/2024
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
5
Document Has Been Signed on
01/25/2024 05:51 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:
01/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, the licensee did not comply with the section cited above in the Emergency Disaster Drill Log, which did not have a drill recorded within the last quarter, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/01/2024
Plan of Correction
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2
3
4
Licensee agrees to conduct an Emergency Disaster Drill and submit an updated Emergency Disaster Drill Log to CCL by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:
Sarah Yip
TELEPHONE:
(408) 324-2131
LICENSING EVALUATOR NAME:
David Marrufo
TELEPHONE:
(650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE:
01/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/25/2024
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
01/25/2024 05:51 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:
01/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(16)
(b) Each resident’s record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)]records review 5 out of 6 resident records did not have a Safeguard for Resident Personal Property and Valuables form, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/01/2024
Plan of Correction
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2
3
4
Licensee agrees to complete a Safeguard for Resident Personal Property and Valuables form for all residents who are missing the form and submit copies to CCL by POC date.
Type B
Section Cited
CCR
87412(a)(13)(A)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (A) A signed statement regarding their criminal record history as required by Section 87355(d).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, the licensee did not comply with the section cited above in 1 out of 1 staff did not have a Criminal Record Statement form, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/01/2024
Plan of Correction
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2
3
4
Licensee agrees to complete a Criminal Record Statement form for S6 and submit a copy to CCL by POC date.
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:
Sarah Yip
TELEPHONE:
(408) 324-2131
LICENSING EVALUATOR NAME:
David Marrufo
TELEPHONE:
(650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE:
01/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/25/2024
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
01/25/2024 05:51 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:
01/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff did not have a Health Screening form, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/01/2024
Plan of Correction
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2
3
4
Licensee agrees to submit a copy of a Health Screening form for staff S4 to CCL by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:
Sarah Yip
TELEPHONE:
(408) 324-2131
LICENSING EVALUATOR NAME:
David Marrufo
TELEPHONE:
(650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE:
01/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/25/2024
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
01/25/2024 05:51 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:
01/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 2 outside passageways; one of the passageways could not be opened during visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/26/2024
Plan of Correction
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2
3
4
Licensee agrees to submit a plan of correction by POC date to CCL stating how the Licensee plans to fix the broken passageway so that its opening is no longer obstructed. Licensee shall submit photographic evidence.
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.
SUPERVISOR'S NAME:
Sarah Yip
TELEPHONE:
(408) 324-2131
LICENSING EVALUATOR NAME:
David Marrufo
TELEPHONE:
(650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE:
01/25/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/25/2024
LIC809
(FAS) - (06/04)
Page:
5
of
5