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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202666
Report Date: 06/04/2024
Date Signed: 06/04/2024 12:49:59 PM

Document Has Been Signed on 06/04/2024 12:49 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:TOUCH OF LIFE RESIDENTIAL CARE FACILITY INCFACILITY NUMBER:
435202666
ADMINISTRATOR/
DIRECTOR:		DEVANO, BELINDAFACILITY TYPE:
740
ADDRESS:2748 ASHLEY CTTELEPHONE:
(408) 854-0735
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 6CENSUS: 4DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Belinda Devano - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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On 06/04/2023 at 9:05 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, Belinda Devano and stated the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over 5 non-ambulatory of which 1 may be bedridden. The facility has a waiver for 4 hospice care. The facility's has 4 residents (R1 to R4) that have neurocognitive impairment. 2 staff were present at the time of the visit. 4 residents were present at the facility. 2 out of 4 were in the dining area. 2 out of 4 residents are in the bedroom and 1 out of 4 is bedridden and 3 out of 4 are under hospice care.

At 9:10 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, 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 70.1 degrees F.

LPA and ADM toured the 4 resident bedrooms and LPA observed the rooms to be organized and free from debris and has sufficient storage for resident's personal belongings. Residents' bed has a motion alarm system to alert staff if assistance is needed. ADM stated the facility has a night on call staff if a resident is awake after 10:00 p.m. and stays with the resident.

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. page 1 of 2 (SEE LIC 809C).
Romeo Manzano
Maria Partoza
DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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 2
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: TOUCH OF LIFE RESIDENTIAL CARE FACILITY INC
FACILITY NUMBER: 435202666
VISIT DATE: 06/04/2024
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The door going out to the backyard opens 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) LPA observed B1 and B2 have non-skid mats and grab bars and a raised toilet seats with handles. LPA with ADM tested the water temperature for kitchen and bathrooms, water temperature was measured at 107.6 degrees F to 116.2 degree F.

LPA observed Dining and kitchen area and living room area were observed to be sanitary and organized. The knives are locked and not easily accessible. Cleaning supplies are separated and locked securely inside a cabinet. 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 and maintained on 6/4/2024.

LPA and ADM inspected the garage. LPA observed washer and dryer located in the garage are in good working condition. LPA observed that the medication is in a locked cabinet. The facility has a first aid cabinet with first aid supplies and accessible to staff.

LPA reviewed facility record, 2 out of 2 staff record and 4 out of 4 resident record and facility records.
Facility's fire drill training conducted on 4/5/2024, 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. Summer Wellness Preparedness readiness training was conducted on 5/29/2024.

LPA reminded ADM of license renewal that is due on 6/27/2024. LPA requested updated documents, LIC 500, lease agreement, updated liability insurance and LIC 308.

NO deficiencies during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with ADM Belinda Devano. A copy of the report was provided.
Page 2 of 2 - END OF REPORT
SUPERVISOR'S NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC809 (FAS) - (06/04)
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