435202664-5-21-2024-26-AS-MPAA-D5GRF3-20240521125829

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202664
Report Date: 05/21/2024
Date Signed: 05/21/2024 12:58:49 PM

Document Has Been Signed on 05/21/2024 12:58 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:	MINA'S ELDERLY CARE HOME 3 LLC		FACILITY NUMBER:	435202664
ADMINISTRATOR:	ABBASVAND, MINA		FACILITY TYPE:	740
ADDRESS:	427 RICHLEE DR		TELEPHONE:	(408) 272-7946
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	6	CENSUS: 6	DATE:	05/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Mina Abbasvand - Administrator		TIME COMPLETED:	01:00 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 5/21/2024 at 8:45 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived and conducted an unannounced required 1 year inspection visit. LPA was greeted by 2 staff. Administrator, Mina Abbasvand was not present upon LPA's arrival. Staff contacted administrator and arrived shortly thereafter and stated the purpose of the visit. LPA observed a NO SMOKING OXYGEN IN USE sign posted on the door prior to entering the facility and at appropriate area of the facility. ADM stated no resident in care is currently using oxygen. The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over 6 non-ambulatory, 1 out 6 may be bedridden and a waiver for 2 hospice care. The facility's has 6 residents (R1 to R6) that have neurocognitive impairment. 2 staff were present at the time of the visit. 6 residents were present at the facility and 3 out of 6 were in the living/dining area. LPA observed 3 out of 6 residents are in the bedroom and 2 out of 6 residents are under hospice care. At 8:55 a.m. LPA toured the facility inside and outside with ADM, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, staff room, backyard and walkways. LPA observed the Personal Rights disclosure, Long Term Care Ombudsman (LTCO) and Centralized Complaint and Information Bureau (CCIB) of the CA Department of Social Services (CDSS) prominently posted on the wall, visible to visitors, resident and staff. The temperature inside the home was at 68 to 69.8 degrees F. LPA and ADM toured the 5 bedrooms and LPA observed the rooms to be organized and free from debris and has sufficient storage for resident's personal belongings. Resident's bedroom has a call alarm system to alert staff if assistance is needed. Three resident bedrooms (Rooms #2,3 and 5) have exit doors and are free from obstruction. 1 of 5 bedroom is shared by 2 residents. LPA observed 5 out of 5 residents' bedroom are sanitary and free from debris. page 1 - see LIC 809C for page 2

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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 4

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: MINA'S ELDERLY CARE HOME 3 LLC	FACILITY NUMBER: 435202664
	VISIT DATE: 05/21/2024

NARRATIVE

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continued from page 1

LPA observed that the facility has a wall pull fire alarm system connected to the fire department emergency line and a carbon monoxide alert system that is in good working condition. LPA observed night lights on the hallway. Hallways are free from obstruction. The sliding door going out to the back deck/patio slides easily and free from obstruction. LPA observed ramps and walkways are free from obstruction. LPA observed the backyard area to be free from debris and is maintained.

LPA with ADM toured 2 full bathrooms (B1, B2) and 1 half bathroom (B3). LPA observed B1 to have skid mats and grab bars and a raised toilet seat that that ha a clear tape wrapped on the back seat. LPA observed the tape has moisture and has black spots. ADM stated B1 is used by staff, but residents can use the bathroom if needed and the raised toilet seat is for the residents. LPA observed a crack on the base of the sink faucet of B1. ADM stated the residents does not take showers in B1 and trash bin has lid. LPA observed a storage area inside the B1 with accordion door. The facility stores incontinent supplies and unopened, unused cleaning and laundry supplies. LPA observed a lock on the accordion door. LPA with ADM inspected the staff room. LPA observed the horizontal structure of the window inside the staff room is sagging with the seal peeling off.

LPA inspected B2 located on the left side of the facility across room 3, 4 and 5 with ADM and observed that the metal trash bin has lid and has signs of rust at the bottom. LPA inspected the bottom cabinet by the sink and found cleaning supplies such liquid bleach (Clorox), and bar powder cleaner (Comet) one of the cabinet door stays locked and one can be opened to access personal products such as lotions, and liquid bath soaps used by residents. LPA observed the bleach was easily accessible at the time of inspection.

LPA tested the water temperature for kitchen and bathrooms, water temperature was measured at 109.2 degrees F to 110.9 degree F. Dining and kitchen area and living room area were observed to be sanitary and organized. The facility has sufficient supply of perishable food for 2 days and non-perishable food for 7 days. The fire extinguisher located in the kitchen was last inspected on 8/29/2023.

Page 2 see LIC 809C page 3

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: MINA'S ELDERLY CARE HOME 3 LLC	FACILITY NUMBER: 435202664
	VISIT DATE: 05/21/2024

NARRATIVE

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LPA and ADM inspected the laundry area. LPA observed the laundry area has a curtain, washer and dryer are in good working condition, the laundry area has a cabinet above that does not have a lock, and contained laundry detergents. LPA with ADM inspected the medication cabinet. LPA observed the medication room is locked and is not easily accessible. LPA observed first aid kit inside the medication cabinet. LPA observed a staff in the kitchen during the time of visit and staff showed LPA that knives and sharp are locked after use.

LPA reviewed facility record, 3 out of 3 staff record and 3 out of 6 resident record.
Facility's fire drill training conducted on 1/15/2024, facility records are up to date. Staff training records were up to date. Staff records were reviewed with current first aid certifications, clearance and training. Residents files were reviewed to be complete. Residents' medications are labeled and current.

Deficiencies are cited during today's visit based on the California Code of Regulations (CCR) Title 22, see LIC 809D. An exit interview was conducted with administrator Mina Abbasvand. A copy of the report and appeals rights were provided.

end of report
page 3

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/21/2024 12:58 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: MINA'S ELDERLY CARE HOME 3 LLC	FACILITY NUMBER: 435202664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 on 2 out of 2 observation. LPA observed the staff room window horizontal structure has water damage, sagging and seal was peeling off. The bathroom faucet sink was cracked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	ADM stated that a maintenance person will be called in as soon as possible to get the window structure in the staff room repaired together with the cracked sink faucet in bathroom 1 (B1). ADM stated she will email the plan of correction to LPA by the POC due date.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 count 2 of 2. LPA observed a cleaning solution was readily accessible to residents in the B2 (resident's bathroom) and laundry detergents are not locked in the laundry area, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	ADM stated that the all cleaning solutions and laundry detergents will be locked and she/he will conduct staff training on safety regarding safety of residents in care by keeping all toxics out of reach and inaccessible to persons in care.

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: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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