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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202793
Report Date: 11/15/2023
Date Signed: 11/15/2023 05:36:37 PM

Document Has Been Signed on 11/15/2023 05:36 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:KOEN ARFFACILITY NUMBER:
435202793
ADMINISTRATOR:KOEN, DEREKFACILITY TYPE:
735
ADDRESS:1620 RAVENS PLACE WAYTELEPHONE:
(646) 423-7601
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Staff Catherine KoenTIME 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 member S1, Catherine Koen. During visit, LPA observed 6 residents and 2 staff.

LPA toured the facility inside out with S1 which included; the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area and second floor of the facility was also inspected. Front yard and backyard were inspected. LPA observed the garage being used as a storage area. There was no obstruction to block the walkways.

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 degrees F, and hot water temperature was measured at 118 degrees F in both resident bathrooms.

Fire extinguishers were serviced in November 2023. 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's last drill was on October 5, 2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff (S1 to S2) and 3 residents (R1-R3). LPA requested to review 3 resident P&I records. S1 stated he/she was doing a review of the resident's P&I records and left the binder with the funds back at his/her home in Morgan Hill.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Staff member, Catherine Koen. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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Document Has Been Signed on 11/15/2023 05:36 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/15/2023 at 05:25 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: KOEN ARF
FACILITY NUMBER: 435202793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client 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 resident P&I records to review and audit. Staff S1 stated he/she took the files home to review the records and the P&I records were not available in the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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ADM stated he/she will send a letter of understanding regarding the regulation and its importance in keeping residents P&I records at the facility. ADM stated he/she will send photo showing records are back at facility to LPA by POC date.
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: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
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