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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202736
Report Date: 10/21/2023
Date Signed: 10/22/2023 07:35:32 PM

Document Has Been Signed on 10/22/2023 07:35 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:KINGDOM HEARTS CARE HOMEFACILITY NUMBER:
435202736
ADMINISTRATOR:ABLAN, RYAN MFACILITY TYPE:
740
ADDRESS:3633 HEATHCOT COURTTELEPHONE:
(408) 262-0425
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 4DATE:
10/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Staff member Melanie AblanTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff member Melanie Ablan, (S1). (LPA observed 3 staff on duty during visit, including staff member S1)

LPA toured the facility inside out with S1 which included; the Living room, kitchen, dinning room, two restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring resident bedrooms, LPA observed Senna & Tums medication in resident bedroom #4's bathroom sink cabinet. (Photographs were taken.). S1 stated resident R1's has been stubborn. S1 stated R1 will ask family to bring him/her medication and R1 will hide medication in his/her room. R1's physicians report,dated June 13, 2023, states that R1 cannot administer his/her own medications. R1's physician report also states R1 is not able to store his/her own medications and is "unable to differentiate medications."

Wile touring the backyard, LPA observed detergent and fabric softener next the facility washing machine. (Photographs were taken.) Resident R2 was sitting in the family room, approximately 5 feet away from the sliding door, which is directly next to the laundry area. S1 stated resident R1 also goes to the backyard on some occasions.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degree F, and hot water temperature was measured to range from 108 to 110 degrees F in both resident bathrooms.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: KINGDOM HEARTS CARE HOME
FACILITY NUMBER: 435202736
VISIT DATE: 10/21/2023
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Fire extinguisher was serviced in May 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on September 16, 2023.

LPA reviewed facility records for 2 staff & 2 residents. LPA reviewed 2 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff (S1 to S2) and 2 residents (R1-R2).

A deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Ryan Ablan, and staff member Melanie Ablan signed on his behalf. Appeal rights were provided.

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

DATE: 10/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/22/2023 07:35 PM - It Cannot Be Edited


Created By: Manuel Monter On 10/21/2023 at 10:30 AM
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: KINGDOM HEARTS CARE HOME
FACILITY NUMBER: 435202736

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, the licensee did not comply with the section cited above. LPA observed detergent and fabric softener acsseible to residents in care in the laundry area. R2 was sitting in the family room, approximately 5 feet away from the sliding door, which is directly next to the laundry area. S1 stated resident R1 also goes to the backyard on some occasions. this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2023
Plan of Correction
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ADM stated he will send plan of action on how the facility will ensure cleaning solutions are not accessilbe to residents in care. ADM stated he will send plan to LPA by POC date, 10/22/2023.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview,record review, the licensee did not comply with the section cited above. LPA observed medication in resident bedroom #4's bathroom sink cabinet. S1 stated R1 will ask family to bring medication and R1 will hide medication in his/her room. R1's physicians report,dated June 13, 2023, states that R1 cannot administer/ store his/her own medications. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2023
Plan of Correction
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ADM stated he will send plan of action on how the facility will keep medication safe and locked, inaccessible to residents in care. ADM stated he will send plan to LPA by POC date, 10/22/2023.
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: 10/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2023


LIC809 (FAS) - (06/04)
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