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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202643
Report Date: 01/31/2024
Date Signed: 01/31/2024 01:26:16 PM


Document Has Been Signed on 01/31/2024 01:26 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:AMY'S RESIDENTIAL CARE, INC.FACILITY NUMBER:
435202643
ADMINISTRATOR:SINGH, JAGTARFACILITY TYPE:
740
ADDRESS:671 N WHITE RDTELEPHONE:
(408) 898-8784
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 6DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator Amarjeet MannTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Amarjeet Mann. During visit, LPA observed 6 residents and 2 staff.

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 3 restrooms and 7 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 74 degrees F, and hot water temperature was measured at 118 degrees F in both resident bathrooms.

Fire extinguisher was serviced in October 9, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on January 23, 2024.

LPA reviewed facility records for 3 staff. LPA reviewed facility resident records for 3 residents. LPA requested resident weight records for R1-R3. ADM stated she only measures the residents weight when they go to their annual doctors visit. LPA reviewed 3 resident medications and centrally stored medication records. While reviewing R2's medication records, LPA discovered discrepancy in medication bottle #1. R2's medication states give two tablets by mouth nightly, with a start date of 12/16/23, and a pill count of 100. LPA reviewed R2's MAR, and there was no refusals. LPA audited the medication and observed only 5 tablets available. ADM does not know why there is an odd number of tablets.
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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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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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: AMY'S RESIDENTIAL CARE, INC.
FACILITY NUMBER: 435202643
VISIT DATE: 01/31/2024
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LPA also reviewed Resident R3's medications. R3's medication bottle #1 states take 1 tablet daily, with a pill count of 90. The centrally stored medication log states the medication was being administered starting 12/22/2024. A review of R3's MAR, shows the medication was not refused, and has been administered. An audit of R3's medication showed a total of 53 pills. LPA asked ADM why there was a discrepancy, if the medication began on 12/22/23 ( 10 days of medication administration in the month of December and 31 days for the month of January, 31+10=41) If 41 tablets have been administered, then the medication bottle needs to have 49 pills, because the facility MAR shows zero refusals. ADM stated she is unsure why there is an excess of 4 medication pills.

LPA conducted interviews with 2 staff (S1 & S2) and 2 residents (R1 & R2).

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Amarjeet Mann and a copy of the signed report & appeal rights were provided.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2024 01:26 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: AMY'S RESIDENTIAL CARE, INC.
FACILITY NUMBER: 435202643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review & interview, the licensee did not comply with the section cited above in 3 Out of 3 resident records reviewed. LPA requested to review R1-R3's weight records. ADM stated she only measures the residents weight when they go to their annual doctors visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2024
Plan of Correction
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ADM stated she will send a plan of action on how the facility will track the residents weight. ADM stated she will send plan of action to LPA by POC date.
Type B
Section Cited
CCR
87207
87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. . R2's medication #1 was a pill short. R3's medication #1 had an excess of 4 medications, but their MAR showed no refusals. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2024
Plan of Correction
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Administrator will submit a written plan on understanding regulations and schedule in-services and training to staff by POC date. Administrator agreed and understood.
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: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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