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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202749
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:32:06 PM

Document Has Been Signed on 01/25/2024 04:32 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:CARING HANDS RESIDENTIAL LIVING IIFACILITY NUMBER:
435202749
ADMINISTRATOR:OKORO, SYLVESTER OFACILITY TYPE:
740
ADDRESS:1324 BAGELY WAYTELEPHONE:
(614) 747-3443
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: 3DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Staff Member Abijuan BurchellTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff Member (S1) Abijuan Burchell . During visit, LPA observed 2 residents and 1 staff. S1 called Administrator Sylvester Okoro, via phone, and informed the ADM the purpose of the visit.

LPA toured the facility inside out with S1 which included; the Living room, kitchen, 2 restrooms and 5 residents bedrooms. While touring the restrooms, LPA observed a bottle of Lysol all purpose cleaner in the private bathroom, in resident bedroom #2. (photograph was taken). LPA also observed shower curtain rod in the private bathroom was laying on the side, in resident bedroom #2. The shower in the private bathroom, for resident bedroom #2 does not have an attached shower curtain. (photograph was taken. ) LPA observed the private bathroom for Resident bedroom #2 does not have a non-skid mat.

While touring the bedrooms, LPA observed an indentation in the hallway opening to bedroom 4 & 5. The indentation can is located on the hardwood floor, with grey duct tape. Resident bedroom #5 is a non ambulatory room. S1 opened the living room closet, and the doors hinges on the top were not attached. When S1 attempted to close the closet door, he/she needed to lift the door. (photographs were taken.)

Front yard and backyard were inspected. While touring the backyard of the facility, LPA observed a can of "Henry-Wet patch, roof leak repair", directly outside Room #3's window. (Photograph was taken.) LPA also observed bedroom #4 does not have a sliding screen for the door facing the patio. LPA observed bedroom #3's window screen was not attached and had an opening. LPA observed bedroom #2's sliding screen door was missing as well. LPA observed a sliding screen on top of a table in the patio. (Photographs were taken.) There was no obstruction to block the walkways.

Page 1 out of 3
Romeo Manzano
Manuel Monter
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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 8
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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749
VISIT DATE: 01/25/2024
NARRATIVE
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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 73 degrees F, and hot water temperature was measured at 115 degrees F in both resident bathrooms.

Fire extinguisher was serviced in October 25, 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 August 23, 2023.

LPA reviewed facility records for 3 residents. While reviewing R1's Needs and services plan, dated April 23, 2021, the form is blank under socialization, emotional, mental, physical, functioning needs. A review of R1's physician report, dated April 22, 2021, states R1 is non ambulatory, and "needs assistance while in bed, as needed during the day while up."

According to Title 22 code of regulations, 87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. While reviewing R2's file, LPA observed R2's physicians report, dated, September 9, 2020. The physician report states R2 has a neurocognitive disorder. LPA reviewed Resident R3 file. LPA observed R3's physicians report, dated November 29, 2022. R3's physician report states R3 has a neurocognitive disorder. R3's Needs and services plan is dated December 23, 2022. LPA asked S1 if there was an updated physician report for R2 and R3. S1 stated what's in the file is what the facility had.

LPA reviewed 3 resident medications and centrally stored medication records. While reviewing R1's medication's, LPA observed over 2 dozen medications, not secured in their container. (photograph was taken) LPA conducted interviews with 1 staff (S1) and 2 residents (R1-R2).

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SUPERVISOR'S NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749
VISIT DATE: 01/25/2024
NARRATIVE
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LPA requested to review 3 staff files. S1 provided 1 staff file. LPA requested to see 2 additional files. S1 stated that was the only one in the facility. S1 called ADM at approximately 1:07pm. S1 stated he/she spoke with ADM. S1 stated there are no other staff files in the facility. S1 stated the other staff files are in the other home.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with ADM at approximately 3:04pm and stated Staff Member Abijuan Burchell could sign on his behalf and a copy of the signed report & appeal rights were provided. Page 2 out of 2.

Page 3 out of 3.
SUPERVISOR'S NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 01/25/2024 04:32 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/25/2024 at 02:30 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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. While reviewing R1's medication's, LPA observed over 2 dozen medications, not secured in their container. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will ensure residents medications are stored in their original container. ADM stated he will also send letter of understanding regarding regulation. ADM stated he will send letter by POC date, 1/26/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 01/25/2024 04:32 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/25/2024 at 02:30 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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, 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 shower in the private bathroom, for resident bedroom #2 does not have an attached shower curtain. LPA observed an indentation in the hallway opening to bedroom 4 & 5. LPA also observed the living room closet, and the doors hinges on the top were not attached. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will keep be good repair at all times. ADM stated he will send plan of action to LPA by POC date, 2/1/2024.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed bedroom #4 does not have a sliding screen for the door facing the patio. LPA observed bedroom #3's window screen was not attached and had an opening. LPA observed bedroom #2's sliding screen door was missing as well. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will keep all screens clean and in good repair. ADM stated he will send plan of action to LPA by POC date, 2/1/2024.
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: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 01/25/2024 04:32 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/25/2024 at 02:30 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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed the private bathroom for Resident bedroom #2 does not have a non-skid mat which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will ensure non-skid mats or strips shall be used in all bathtubs and showers. ADM stated he will send plan of action to LPA by POC date, 2/1/24.
Type B
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 LPA's observation, the licensee did not comply with the section cited above. LPA observed a bottle of Lysol all purpose cleaner in the private bathroom, in resident bedroom #2. While touring the backyard of the facility, LPA observed a can of "Henry-Wet patch, roof leak repair", directly outside Room #3's window. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will ensure disinfectants, poisons and other items which could pose a danger are inaccessible to residents in care. ADM stated he will send plan of action to LPA by POC date, 2/1/24.
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: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 01/25/2024 04:32 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/25/2024 at 02:30 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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested 3 staff files. S1 only provided 1 and stated there were no other files. S1 contacted ADM, and informed LPA the other staff documents were at another facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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ADM stated he will send LPA plan of action on how the facility will ensure staff records are available to inspect during normal business hours. ADM stated he will send plan of action to LPA by POC date, 2/1/24.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R1's Needs and services plan, dated April 23, 2021, the form is blank under socialization, emotional, mental, physical, functioning needs. A review of R1's physician report, dated April 22, 2021, states R1 is non ambulatory, and "needs assistance while in bed, as needed during the day while up." This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will ensure appraisals are updated as frequently as possible. ADM also stated he will update R1's needs and services plan. ADM stated he will send an updated copy to LPA by POC date, 2/1/2024.
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: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 01/25/2024 04:32 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/25/2024 at 02:30 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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Based on facility records the last drill conducted was on August 23, 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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2
3
4
ADM stated he will conduct a drill by POC date and send LPA documentation that a drill has taken place. ADM stated he will send plan of corrections by POC date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. While reviewing R2's file, LPA observed R2's physicians report (PR), dated, 9/9/20. The PR states R2 has a neurocognitive disorder. LPA observed R3's PR, dated 11/29/22. R3's PR states R3 has a neurocognitive disorder. R3's Needs and services plan is dated 12/23/22. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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2
3
4
ADM stated he will send plan of action on how the facility will ensure Each resident with dementia shall have an annual medical assessment and a reappraisal done at least annually. ADM stated he will send plan of action by POC date, 2/1/2024.
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: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
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