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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202671
Report Date:
04/08/2024
Date Signed:
04/09/2024 08:13:08 AM
Document Has Been Signed on
04/09/2024 08:13 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EDRICBOYLYNN RESIDENTIAL CARE HOME INC
FACILITY NUMBER:
435202671
ADMINISTRATOR/
DIRECTOR:
REMEDIOS SINGSON
FACILITY TYPE:
735
ADDRESS:
1307 PARK PLEASANT CIR
TELEPHONE:
(408) 929-4958
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95127
CAPACITY:
6
CENSUS:
5
DATE:
04/08/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:
Remedios Singson
TIME VISIT/
INSPECTION COMPLETED:
04:39 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Remedios Singson.
4 staff and 2 residents were observed in the facility, and 3 residents went to day program.
LPA toured the facility inside out with ADM. License, administrator certificate, and personal rights posters were observed in the facility. Family room, kitchen, dinning room, one office and two restrooms were inspected. Two staff live-in rooms were observed in the facility. Two single resident bedrooms, two resident shared rooms and laundry area were inspected. Two staff live-in rooms are in facility.
Medication closet, and cleaning product closet were observed locked. knives closet was observed unlocked, ADM locked the knives closet immediately. Room temperature was at 68 degree F, and hot water temperature was at 119 degree F in facility. First aid box was observed in the facility. Flash rights were observed run of battery.
Fire extinguisher was serviced on 08/07/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by staff, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.
The last time the facility conducted the emergency drill was on 11/27/2023.
Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME
:
Romeo Manzano
LICENSING EVALUATOR NAME
:
Chihhsien Chang
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/08/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/08/2024
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
04/09/2024 08:13 AM
- It Cannot Be Edited
Created By:
Chihhsien Chang
On
04/08/2024
at
03:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EDRICBOYLYNN RESIDENTIAL CARE HOME INC
FACILITY NUMBER:
435202671
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in that the knives closet was observed unlocked during the inspection which poses an immediate health, safety risk to persons in care.
ADM locked the knives closet immediately.
POC Due Date:
04/09/2024
Plan of Correction
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2
3
4
ADM stated to submit a plan of correction by the POC due date to lock the knives closet.
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:
Romeo Manzano
LICENSING EVALUATOR NAME:
Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE:
04/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/08/2024
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
04/09/2024 08:13 AM
- It Cannot Be Edited
Created By:
Chihhsien Chang
On
04/08/2024
at
03:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EDRICBOYLYNN RESIDENTIAL CARE HOME INC
FACILITY NUMBER:
435202671
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that gnats were observed in the backyard nera the laundry area which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
04/15/2024
Plan of Correction
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4
ADM stated to submit a plan of correction by the POC due date to remove gnats in the backyard.
Type B
Section Cited
CCR
85088(e)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that flshlights were observed run of of battery which poses/posed a potential safety risk to persons in care.
POC Due Date:
04/15/2024
Plan of Correction
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2
3
4
ADM stated to submit a plan of correction by the POC due date to install battery for flashlight.
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
LICENSING EVALUATOR NAME:
Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE:
04/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/08/2024
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
04/09/2024 08:13 AM
- It Cannot Be Edited
Created By:
Chihhsien Chang
On
04/08/2024
at
03:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EDRICBOYLYNN RESIDENTIAL CARE HOME INC
FACILITY NUMBER:
435202671
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that the sensor night light was observed not working which poses/posed a potential safety risk to persons in care.
POC Due Date:
04/15/2024
Plan of Correction
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3
4
ADM stated to submit a plan of correction by the POC due date to fix the sensor night light.
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that client appraisal Needs and Service Plan was observed updated annually and was not signed by client/family which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/15/2024
Plan of Correction
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4
ADM stated to submit a plan of correction by the POC due date to have client appraisal Needs and Service Plan updated annually and signed by client/family.
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
LICENSING EVALUATOR NAME:
Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE:
04/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/08/2024
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
04/09/2024 08:13 AM
- It Cannot Be Edited
Created By:
Chihhsien Chang
On
04/08/2024
at
03:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
EDRICBOYLYNN RESIDENTIAL CARE HOME INC
FACILITY NUMBER:
435202671
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/08/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, record review, the licensee did not comply with the section cited above in that 1 out of 3 client's P & I money was not matched with the P & I money log which poses/posed a potential personal rights risk to persons in care.
POC Due Date:
04/15/2024
Plan of Correction
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2
3
4
ADM stated to submit a plan of correction by the POC due date to make sure client's P & I money was maintained accurately.
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
LICENSING EVALUATOR NAME:
Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE:
04/08/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/08/2024
LIC809
(FAS) - (06/04)
Page:
5
of
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