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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202680
Report Date: 11/28/2023
Date Signed: 11/29/2023 04:25:37 PM

Document Has Been Signed on 11/29/2023 04:25 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:VINCI PARK ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202680
ADMINISTRATOR:MELDA RIPARIP ANTONIOFACILITY TYPE:
735
ADDRESS:5875 HERMA STREETTELEPHONE:
(408) 518-2250
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 4CENSUS: 4DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator/Licensee, Melda Riparip AntonioTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Simi Rai and Mita Partoza conducted an unannounced Required 1 Year visit and met with Administrator/Licensee (LIN), Melda Riparip Antonio. LPAs observed 2 staff at the facility. 4 residents were attending day program.

During visit, LPAs toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPAs observed the backyard wall facing the facility is shared with the freeway. There is a door that leads to the freeway and LPAs observed the door to be bolted into the wall and cannot be opened.

LPAs toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai and LPA Partoza observed a closet in the backyard that was locked. LIN opened the closet and stated Staff (S2) uses the closet for personal items such as clothes and personal grooming. LIN stated Staff (S2) will sleep in the sofa in the living room overnight while S2 works in the facility 5 days in a week. LIN stated the facility does not have fire clearance for the living room to be used as a bedroom.

Continuation LIC 809-C, Page 1 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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 6
Document Has Been Signed on 11/29/2023 04:25 PM - It Cannot Be Edited


Created By: Simranjit Rai On 11/28/2023 at 12:37 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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2023
Section Cited

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85087 Buildings and Grounds(a)(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met by:
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Based on observation and interview, Licenee stated staff are sleeping in the living room and using it as a bedroom at night which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
11/29/2023
Section Cited

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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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Based on record review, interview and observation R1's 1 out of 9 meds not administered to R1 as prescribed by the MD which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/29/2023 04:25 PM - It Cannot Be Edited


Created By: Simranjit Rai On 11/28/2023 at 12:42 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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2023
Section Cited

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80075 Health Related Services(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
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Based on interview and record review, S1's first aid training was expired which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/29/2023 04:25 PM - It Cannot Be Edited


Created By: Simranjit Rai On 11/28/2023 at 01:20 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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2023
Section Cited

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80088 Furniture, Fixtures, Equipment, and Supplies - (e) Faucets used by clients for personal care ... (1) Hot water temperature controls shall be maintained temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
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This requirement is not met as evidenced by:
The bathroom #1 sink measured hot water at 124.9 F and the bathroom #2 sink measured hot water at 126.7F which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


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Page: 4 of 6
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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680
VISIT DATE: 11/28/2023
NARRATIVE
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Page 2 of 3.

The facility bathroom had available soap, paper towels, and trash cans with lids. The shower had grab bars and non-skid mats. The water temperature in the bathroom sinks ranged from 124.9F - 126.7F. The water temperature in the kitchen sink was 123.8F. Fire extinguisher was observed and purchased on 11/6/2023. Facility smoke detectors and carbon monoxide detectors were in working condition. 4 out of 4 resident bedrooms had available bedding, drawers, and functioning lights.

LPAs reviewed facility records for 2 staff and 2 residents. LPAs observed S1 had expired first aid training on file which expired 11/17/2023. Licensee was not aware the first aid training was expired. Licensee required S1 to complete the first aid training during today's visit. Licensee was able to provide a completion certification.

LPAs reviewed resident medications and central stored medication records. During a random review/audit of resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record, 1 out of 9 medications prescribed to R1 was not given as prescribed by the doctor. LPAs Rai and Partoza along with LIN counted the tablets from the medication bottles.
R1's medication #1 were counted 20 tablets instead of 22/30 tablets, 1 medication tablets was missing from the bottle. Based on review of R1's Medication Administration Records (MARs), LIN stated that R1's medications were administered twice a day from 11/24/2023 to today. LIN stated R1's physician did not place the medication on hold and R2 did not refuse to take medication. Based on review of R1's MARs there was no note stated medication was on hold or R1 did not refuse.

LPA Rai and LPA Partoza interviewed Staff (S1) who opened the new medication #1 bottle and administered the medication to R1. S1 stated the medication bottle was opened on 11/24/2023 and the medication was administered the evening of 11/24/2023.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680
VISIT DATE: 11/28/2023
NARRATIVE
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Page 3 of 3.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs.

Exit interview was conducted with Administrator/Licensee, Melda Riparip Antonio. A copy of this report was provided to Administrator/Licensee, Melda Riparip Antonio. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
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