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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202770
Report Date:
05/09/2024
Date Signed:
05/10/2024 08:23:20 AM
Document Has Been Signed on
05/10/2024 08:23 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
2580 N. FIRST STREET, STE. 350
SAN JOSE
,
CA
95131
FACILITY NAME:
A AND A RESIDENTIAL CARE HOME, INC.
FACILITY NUMBER:
435202770
ADMINISTRATOR/
DIRECTOR:
FARAKESH, REZA
FACILITY TYPE:
735
ADDRESS:
1084 WALLACE DR
TELEPHONE:
(415) 385-8900
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95120
CAPACITY:
6
CENSUS:
6
DATE:
05/09/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:
Reza Farakesh
TIME VISIT/
INSPECTION COMPLETED:
12:03 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Reza Farakesh.
LPA toured the facility inside and out with ADM. License, Administrator Certificate, and personal rights posters were observed in the facility.4 staff were observed in the facility. LPA reviewed 3 resident file and 3 staff files.
Living room, kitchen, dining room, restrooms, and laundry room were inspected. 4 single resident bedrooms, 1 shared resident bedrooms, and a staff room/office were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet and knives closet were observed locked. Dish washing chemical cabinet was observed unlocked. ADM locked the dish washing chemical cabinet before LPA finished the visit. Room temperature was at 68 degree F, and hot water temperature was at 112 degree F in facility. The temperature of the refrigerator was at 40 degree F. One of the resident room's screen window was observed missing. No flash lights was observed in the facility. No night light was observed in the facility hall way or restroom, ADM installed a night light and got the flash light before LPA finished the visit.
Fire extinguisher was serviced on 05/1/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by ADM, and were working fine. First aid box was observed in the facility. Front yard and backyard were inspected. There was no obstruction to block the walkways. ADM stated the last time the facility conducted the emergency and fire drill was on 1/17/2024.
Deficiencies were noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME
:
Romeo Manzano
LICENSING EVALUATOR NAME
:
Chihhsien Chang
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/09/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/09/2024
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
5
Document Has Been Signed on
05/10/2024 08:23 AM
- It Cannot Be Edited
Created By:
Chihhsien Chang
On
05/09/2024
at
11:22 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:
A AND A RESIDENTIAL CARE HOME, INC.
FACILITY NUMBER:
435202770
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/09/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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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2
3
4
Based on observation, the licensee did not comply with the section cited above in that the dish washing chemical cabinet was observed unlocked which poses an immediate health, safety risk to persons in care.
POC Due Date:
05/10/2024
Plan of Correction
1
2
3
4
Administrator stated to submit a plan of correction by the POC due date to maintain the dish washing chemical cabinet locked.
Administrator locked the dish washing cabinet before LPA finished the visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE:
05/09/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/09/2024
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
05/10/2024 08:23 AM
- It Cannot Be Edited
Created By:
Chihhsien Chang
On
05/09/2024
at
11:22 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:
A AND A RESIDENTIAL CARE HOME, INC.
FACILITY NUMBER:
435202770
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/09/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that one of the resident room's screen window was observed missing which poses/posed a potential health, safety rights risk to persons in care.
POC Due Date:
05/16/2024
Plan of Correction
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2
3
4
Administrator stated to send a plan of correction by the POC due date to install a screen window at the resident room.
Type B
Section Cited
CCR
85088(e)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that no flash light was observed in the facility which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/16/2024
Plan of Correction
1
2
3
4
Administrator stated to submit a plan of correction by the POC due date to have flash lights available in the facility.
ADM put flash lights in the facility before LPA finished the visit.
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:
Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE:
05/09/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/09/2024
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
05/10/2024 08:23 AM
- It Cannot Be Edited
Created By:
Chihhsien Chang
On
05/09/2024
at
11:22 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:
A AND A RESIDENTIAL CARE HOME, INC.
FACILITY NUMBER:
435202770
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/09/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that no night light was observed in the hallway or in the restroom which poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/16/2024
Plan of Correction
1
2
3
4
Administrator stated to submit a plan of correction by the POC due date to install the night lights in the facility.
ADM installed the night nights in the facility before LPA finished the visit.
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.
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 in that 1 out 3 resident appraisal Needs and Service plan was observed not available in the resident file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/16/2024
Plan of Correction
1
2
3
4
Administrator stated to submit a plan of correction by the POC due date to maintain resident files update to date.
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:
Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE:
05/09/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/09/2024
LIC809
(FAS) - (06/04)
Page:
4
of
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