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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202793
Report Date: 11/14/2024
Date Signed: 11/14/2024 12:25:20 PM

Document Has Been Signed on 11/14/2024 12:25 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/
DIRECTOR:		KOEN, DEREKFACILITY TYPE:
735
ADDRESS:1620 RAVENS PLACE WAYTELEPHONE:
(646) 423-7601
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Administrator Derek KoenTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Derek Koen. During the visit, LPA observed 6 residents and 3 staff. LPA explained the purpose of the visit.

As LPA entered the facility, LPA observed 3 staff. LPA asked the staff's name and cross referenced their names with the LIC536, Facility Personnel Report Summary. LPA observed that staff S1 and S2 were not associated with the facility. LPA searched Staff S1 and S2 in guardian, and both staff are fingerprint cleared, but not associated with the facility.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 3 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 upstairs of the facility, LPA observed a shelf directly in front of the stairs. LPA observed a cloth covering the sheet. Behind the sheet was 2 detergent containers and a can of paint. (Photograph was taken.) ADM removed the chemicals and stored them in the staff room, inaccessible to residents in care.

While touring the garage, LPA observed part of the garage was sectioned off with a wall. LPA observed inside this sectioned off part of the garage, a couch, television, cloths, and blankets. (Photographs were taken.) ADM stated he will sometimes sleep in the garage. ADM stated he doesn't know if staff, when on break, will sleep in the garage. Based on a review of the facility sketch, the garage is listed as a garage, which is listed as "off limits." LPA interviewed staff S1 and S2. Both staff interviewed stated staff S4 has been sleeping in the garage for the past month.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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: KOEN ARF
FACILITY NUMBER: 435202793
VISIT DATE: 11/14/2024
NARRATIVE
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While touring resident bedroom #1, LPA observed a dresser that was missing one of the pull out drawers of the dresser was missing. ADM stated he was in the process of fixing it. ADM stated the sliding mechanism of the drawer is not working. (Photograph was taken.) LPA interviewed staff S1 and S2. Both staff interviewed stated the dresser drawer has been damaged for over a week.

While touring the home, LPA observed resident R4 on a wheel chair. LPA reviewed R4's physicians report, dated November 7, 2023, which states R4 is non-ambulatory. Based on a review of the facility fire clearance, the facility is cleared for 6 ambulatory residents and 0 non ambulatory residents.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 116 degrees F in both resident bathrooms.

Fire extinguisher was serviced in November 14, 2024. 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 November 11, 2024.

LPA reviewed facility records for 3 staff and 3 residents. While reviewing Staff S1 and S2's file, LPA observed the LIC 501, LIC508 and SOC341A were under a different facility name. ADM updated staff documents to reflect the current facility. ADM stated he will send LPA a copy of the updated forms.

LPA reviewed 3 resident P&I records. LPA reviewed 3 resident medications and centrally stored medication records. While reviewing resident R1-R3's centrally stored medication log, LPA observed the sections labeled expiration date, date filled and prescription number were not filled out for all 3 residents records reviewed. (Photographs were taken.) LPA conducted interviews with 2 staff and 2 residents.

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

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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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: KOEN ARF
FACILITY NUMBER: 435202793
VISIT DATE: 11/14/2024
NARRATIVE
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Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $1000 ($200 per day x 5 days = $1000) for S1 and S2 working in the facility without association.

This report was reviewed with Administrator Derek Koen and a copy of the signed report was provided. Appeal rights were provided.

Page 3 Out of 3. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/14/2024 12:25 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/14/2024 at 11:44 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: KOEN ARF
FACILITY NUMBER: 435202793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

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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Based on observation, the licensee did not comply with the section cited above. LPA observed a shelf directly in front of the stairs. LPA observed a cloth covering the sheet. Behind the sheet was 2 detergent containers and a can of paint. ADM removed the chemicals and stored them in the staff room, inaccessible to residents in care. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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ADM stated he will send a written plan of action on how he will ensure Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to residents, are inaccessible to residents in care.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2024 12:25 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/14/2024 at 11:44 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: KOEN ARF
FACILITY NUMBER: 435202793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, the licensee did not comply with the section cited above. While touring resident bedroom #1, LPA observed a dresser that was missing one of the pull out drawers of the dresser was missing. ADM stated the sliding mechanism of the drawer is not working. S1 & S2 stated the dresser drawer has been damaged for over a week. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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ADM stated he will send a written plan on action on how he will ensure the facility is clean, safe, sanitary and in good repair at all times for residents. ADM stated he will fix the dresser drawer and send LPA picture.
Type B
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. While touring the home, LPA observed resident R4 on a wheel chair. LPA reviewed R4's physicians report, dated November 7, 2023, which states R4 is non-ambulatory. Based on a review of the facility fire clearance, the facility is cleared for 6 ambulatory residents and 0 non ambulatory residents. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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ADM stated he will send a written plan of action on how he will ensure the facility operates within the conditions and limitations of the license. ADM stated he will
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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/14/2024 12:25 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/14/2024 at 11:44 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: KOEN ARF
FACILITY NUMBER: 435202793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above. LPA observed inside this sectioned off part of the garage, a couch, television, cloths, and blankets. Staff S1 and S2 stated Staff S4 has been sleeping in the garage for over a month. Based on a review of the facility sketch, the garage is listed as a garage, which is listed as "off limits." This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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ADM stated he will send a written plan of action on how he will ensure he is following his fire clearance. ADM stated
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above. LPA asked the staff S1 and S2's name and cross referenced their names with the LIC536. LPA observed that staff S1 and S2 were not associated with the facility. LPA searched Staff S1 and S2 in guardian, and both staff are fingerprint cleared, but not associated with the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will send the forms to associate staff S1 and S2.
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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/14/2024 12:25 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/14/2024 at 11:44 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: KOEN ARF
FACILITY NUMBER: 435202793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above. While reviewing resident R1-R3's centrally stored medication log, LPA observed the sections labeled expiration date, date filled and prescription number were not filled out for all 3 residents records reviewed. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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2
3
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ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will also send an updated copy of resident R1-R3's centrally stored medication record to LPA.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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