435202629-11-2-2022-26-AS-SRAI-CKT3KS-20221102181936

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202629
Report Date: 11/02/2022
Date Signed: 11/02/2022 06:20:09 PM

Document Has Been Signed on 11/02/2022 06:20 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:	BLENDED FAMILY CARE HOME		FACILITY NUMBER:	435202629
ADMINISTRATOR:	PAGKALINAWAN, MICHELLE		FACILITY TYPE:	740
ADDRESS:	10366 MILLER AVENUE		TELEPHONE:	(408) 802-6410
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	12	CENSUS: 11	DATE:	11/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:48 PM
MET WITH:	Michelle Pagkalinawan, Administrator		TIME COMPLETED:	06:30 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	On 11/2/2022 at 1:48pm, Licensing Program Analyst (LPA) Simi Rai and Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced annual visit and met with Administrator (ADM), Michelle Pagkalinawan. ADM stated there is 1 hospice resident and 5 dementia residents at this time. During inspection, LPA and LPM toured the first floor of the facility. Facility has a second floor for staff quarters but is not licensed under the Department. LPA and LPM observed the Receiving Area, Dining Room, Kitchen, Living Room, 8 resident rooms, 7 bathrooms, backyard, and front yard. LPA observed a central entry point for screening visitors and hand sanitizer. LPA observed posters to include hand washing and COVID-19 symptom warnings. Facility has a sufficient amount of PPE supplies. LPA observed paper towels and trash bins with lids. During the tour, LPA observed the laundry room being occupied as a staff living quarters. Based on the physical plant on record, this laundry room does not specify as a staff room. Administrator will contact the landlord if the laundry room has a building permit and fire clearance. Administrator will contact LPA once receiving the information about the status of the laundry room. LPA observed 5 staff members at the facility. Staff #5 is fingerprint cleared but not associated to the facility. Staff #6 is a temporary agency caregiver and ADM stated S6 is fingerprint cleared. LPA observed a non-fingerprinted individual (I1) on the premises (receiving area and laundry area). The non-fingerprinted individual (I1) left the premises during the visit. Continue on LIC 809-C.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

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 11/09/2022 02:28 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/09/2022 11:35 AM

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: BLENDED FAMILY CARE HOME	FACILITY NUMBER: 435202629
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by: LPA observed a non-fingerprinted individual (I1) on the premises (receiving area and laundry area). The non-fingerprinted individual (I1) left the premises during the visit. Administrator submitted an exemption request and the request is still pending.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 individual who does not have an criminal record exemption clearance which poses an immediate health, safety or personal rights risk to persons in care. The invidiual is fingerprinted but requires a criminal record exemption clearance.
	POC Due Date: 11/02/2022
	Plan of Correction
1 2 3 4	Administrator stated the individual will not be on premises until they obtain the exemption. The individual left the premises during the visit. Administrator agreed and understood that the invidiual is not allowed to be working, volunteering or residing in the faciity. The invidiual is fingerprinted but requires a criminal record exemption clearance. Cleared during visit.

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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC809 (FAS) - (06/04)

Page: 4 of 9

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: BLENDED FAMILY CARE HOME	FACILITY NUMBER: 435202629
	VISIT DATE: 11/02/2022

NARRATIVE

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The following documents will need to be updated in the facility file :
1) LIC 500 – Personnel Report
2) LIC 400 – Affidavit Regarding Client/Resident Cash Resources
3) Liability Insurance
4) COVID-19 Mitigation Plan

Deficiencies were cited during today's visit per California Code of Regulations, Title 22.

Civil Penalty was issued LIC 421BG for Criminal Record Clearance. Appeal Rights forms provided and discussed.

Technical Violations and Technical Assistance notes provided.

This report was reviewed with Administrator Michelle Pagkalinawan and staff Karina Quintana and copy of this report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC809 (FAS) - (06/04)

Page: 5 of 9

Document Has Been Signed on 11/02/2022 06:20 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: BLENDED FAMILY CARE HOME	FACILITY NUMBER: 435202629
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care Services (h) The following requirements shall apply to medications which are centrally stored (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication as required by the Department. This requirement is not met as evidenced by: LPA observed prescription medications in R1’s bedroom and advised Administrator to remove and lock the medications immediately. LPA observed an unlocked box of injections filled with medication for a Hospice resident in the refridgerator in the Pantry area.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 3 out of 3 prescription medications and injections which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2022
	Plan of Correction
1 2 3 4	Administrator has removed the prescription medications from the resident's room and placed it in the hygiene locked closet and the staff will remove the medications from the closet and provide the care in the room. Administrator has locked the box of injections in the refridgerator. Administrator will provide Medication and Storage training to the staff and give training log to LPA by POC date.

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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC809 (FAS) - (06/04)

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