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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202749
Report Date: 01/16/2025
Date Signed: 01/16/2025 05:33:09 PM

Document Has Been Signed on 01/16/2025 05:33 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/
DIRECTOR:		OKORO, SYLVESTER OFACILITY TYPE:
740
ADDRESS:1324 BAGELY WAYTELEPHONE:
(614) 747-3443
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:52 PM
MET WITH:Staff Abijuan BurchellTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff Abijuan Burchell. During the visit, LPA observed 3 residents and 2 staff. LPA explained the purpose of the visit.

Staff S1 contacted ADM at 2:02pm. LPA informed ADM, via phone call, that LPA was conducting their annual inspection. ADM stated he could not come to the facility and stated staff S1 could sign on his behalf.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the facility garage, LPA observed the door which leads to the garage does not have a locking mechanism. (Photograph was taken.) LPA observed the facility garage has an assortment of detergents and other cleaning liquids and sprays on the ground, accessible to residents in care. (Photographs were taken.)

While touring the backyard, LPA observed a storage shed in the backyard. LPA asked S1 to open the storage shed. S1 informed LPA the storage shed does not have a lock. LPA observed inside the storage shed, a container of gasoline, paint and other tools. LPA opened container of gasoline and confirmed the container had gasoline liquid inside. (Photograph was taken.)

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area as locked and inaccessible to residents in care. Room temperature was at 76 degrees F, and hot water temperature was measured to range from 116-118 degrees F in both resident bathrooms.
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Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112
DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749
VISIT DATE: 01/16/2025
NARRATIVE
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Fire extinguisher was serviced in October 16, 2024. 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 conducted drills for the year 2024, for the following dates; August 30, 2024, May 31, 2024, and February 18, 2024. LPA asked S1 if a drill had been conducted From September 2024 - January 2025. S1 stated she believes a drill was conducted in November, but it wasn't written down. Staff was unable to produce documentation a drill had taken place in the 4th quarter of 2024.

LPA reviewed facility records for 3 residents. LPA requested to review R1's needs and Services plan (ANS). Based on a review of R1's ANS, the form is blank, only containing the facility's information, the residents name, and dated December 2024. (Photographs were taken). S1 stated the facility was in the process of filling out R1's ANS.

LPA reviewed R3's physician report dated, September 9, 2020. LPA requested to review R3's updated physicians report. Facility staff was unable to produce a copy of an updated physicians report or documentation showing the administrator contacted the residents responsible party to get an updated physicians report. LPA requested to review a copy of R3's needs and services plan. S1 stated ADM sent her a copy. S1 provided LPA with a Needs and Services plan for the facility, "Hearts and Minds Activity Center."

LPA requested to review R4's physicians report and Needs and services Plan. S1 stated those are the forms the facility is still working on filling out. S1 stated R4 has not had a medical assessment yet. LPA was not provided a copy of R4's needs and services plan or physicians report.


Page 2 Out of 3.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
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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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749
VISIT DATE: 01/16/2025
NARRATIVE
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LPA reviewed facility records for 3 staff. LPA requested to review staff S1's training for 2024. S1 stated she did not complete any training for 2024.

LPA reviewed 3 resident medications and centrally stored medication records. While reviewing resident R1-R4's Centrally stored medication records, LPA observed R1,R2 & R4's Centrally stored medication log was not filled out. S1 stated they have not filled out their centrally stored medication record. LPA observed Resident R3's centrally stored medication record had several medications that were not listed and had incorrect information, such as the incorrect prescribing physician. (Photographs were taken.)

The Department is issuing an immediate civil penalty of $250 for each repeat violation for the following deficiencies:
  • 87309 Storage Space & Access (a), which was previously cited on January 25, 2024.
  • 87463 Reappraisals (a), which was previously cited on January 25, 2024.
  • HSC 1569.695(c), which was previously cited on January 25, 2024.


Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
This report was reviewed with Staff Abijuan Burchell and a copy of the report was provided. Appeal Rights was provided.

Page 3 Out of 3. End of Report
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 01/16/2025 05:33 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/16/2025 at 04:42 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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above. LPA observed detergents inside the garage accessible to residents in care. LPA observed the storage shed in the backyard, contained a container of gasoline, which was accessible to residents in care. The door on the shed, does not have a locking mechanism. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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ADM stated he will send a written plan of action on how he will ensure cleaning solutions, poisonous substances, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. ADM stated his written plan will address the storage shed in the backyard and the detergents in the garage, and send to LPA by POC date, 1/17/2025.
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
TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME:Manuel Monter
TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2025 05:33 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/16/2025 at 04:42 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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. LPA requested to review staff S1's training for 2024. S1 stated she did not complete any training for 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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ADM stated he will send a written plan of action on how he will ensure his staff meet the 20 hours of annual training. ADM stated he will send this written plan of action by POC date 1/23/25.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA requested to review R4's physicians report. S1 stated the facility is still working on filling out that form. S1 stated R4 has not had a medical assessment yet. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will send LPA a copy of resident R4's physicians report. ADM stated he will send to LPA by POC date, 1/23/25.
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
TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME:Manuel Monter
TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 01/16/2025 05:33 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/16/2025 at 04:42 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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. R1 needs and Services plan form is blank. S1 stated R4's Needs and services plan has not been filled out. S1 stated the facility was in the process of filling out R1's ANS. Facility staff was unable to provided an updated copy of R3's Needs and services plan. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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ADM stated he will send LPA a letter of understanding regarding the regulation. ADM stated he will send LPA a copy of R1, R2 and R4's updated needs and services plan. ADM stated he will send the plan of correction to LPA by POC date 1/23/2025.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

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. Facility staff was unable to produce a copy of an updated physicians report for R3 or documentation showing the administrator contacted the residents responsible party to get an updated physicians report. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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ADM stated he will send LPA an updated copy of R3's physicians report. ADM stated he will send to LPA by POC date, 1/23/2025.
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
TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME:Manuel Monter
TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 01/16/2025 05:33 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/16/2025 at 04:42 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: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

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
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Based on record review and interview, the licensee did not comply with the section cited above. The facility conducted drills for the year 2024, for the following dates; August 30, 2024, May 31, 2024, and February 18, 2024. Staff was unable to produce documentation a drill had taken place in the 4th quarter of 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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ADM stated he will send LPA a letter of understanding regarding the regulation. ADM stated he will conduct a drill and send LPA documentation showing a drill has taken place.
Type B
Section Cited
CCR
87465(h)(3)
87465 Incidental Medical and Dental Care (h) (3) Each container shall carry all of the information specified in (6)(A) through (E) below plus expiration date and number of refills.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on record review and interview, the licensee did not comply with the section cited above. R1,R2 & R4's Centrally stored medication log was not filled out. S1 stated they have not filled out their centrally stored medication record. R3's centrally stored medication record had several medications that were not listed and had incorrect information, such as the incorrect prescribing physician. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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2
3
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ADM stated he will send LPA a letter of understanding regarding the regulation. ADM stated he will send LPA a copy of R1-R4's updated Centrally stored medication record. ADM stated he will send the plan of action to LPA by POC date, 1/23/25.
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
TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME:Manuel Monter
TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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