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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202680
Report Date: 11/15/2024
Date Signed: 11/15/2024 05:00:57 PM

Document Has Been Signed on 11/15/2024 05:00 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/
DIRECTOR:		MELDA RIPARIP ANTONIOFACILITY TYPE:
735
ADDRESS:5875 HERMA STREETTELEPHONE:
(408) 518-2250
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 4CENSUS: 4DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Administrator Melda Riparip AntonioTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Melda Riparip Antonio. During the visit, LPA observed 4 residents and 2 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 2 residents bedrooms. The staff area of the facility was also inspected. LPA toured the facility garage, which is being used to store a car and as a storage space. The front yard and backyard were inspected. There was no obstruction to block the walkways. LPA also observed two storage sheds in the backyard, being used as storage space.

While touring resident bedroom #4, LPA observed the private bathroom. Inside the private bathroom, contained a toilet and shower. LPA observed the shower to have a layer of hard water stains and orange stains on the floor of the shower and on the walls. (Photographs were taken.)

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 72 degrees F, and hot water temperature was measured at 106-107 degrees F in both resident bathrooms.

Fire extinguisher was serviced in November 15, 2024. 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 conducted fire drills for the year 2024, on the following dates: July 15, 2024, March 4, 2024.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: VINCI PARK ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202680
VISIT DATE: 11/15/2024
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LPA reviewed facility records for 3 staff and 4 residents. LPA reviewed 4 resident medications and centrally stored medication records. LPA reviewed 4 resident P&I records. LPA conducted interviews with 1 staff and 1 resident.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Melda Riparip Antonio and a copy of the signed report was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2024 05:00 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/15/2024 at 04:43 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: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed the private bathroom, inside resident bedroom #4, shower to have a layer of hard water stains and orange stains on the floor of the shower and on the walls. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure the facility will be clean, safe, sanitary at all times for the safety and well-being of residents. ADM stated she will send photo documentation showing the shower inside bedroom #4 has been cleaned.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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. Based on a review of the facility fire drill log, the facility conducted fire drills for the year 2024, on the following dates: July 15, 2024, March 4, 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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ADM stated she will conduct a drill and send LPA documentation showing a drill has taken place. ADM stated she will also send a letter of understanding regarding the regulation.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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