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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202852
Report Date: 04/19/2024
Date Signed: 04/19/2024 04:50:00 PM

Document Has Been Signed on 04/19/2024 04:50 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:EMANUEL'S CARE HOMEFACILITY NUMBER:
435202852
ADMINISTRATOR/
DIRECTOR:		GONZALEZ, DORISFACILITY TYPE:
735
ADDRESS:2053 RADIO AVETELEPHONE:
(408) 592-5303
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 4DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:58 PM
MET WITH:Administrator Doris GonzalezTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Doris Gonzalez. During the visit, LPA observed 4 residents and 1 staff.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 2 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 backyard, LPA requested to see the facility dryer. ADM showed LPA the facility dryer. LPA asked ADM to turn the dryer on, S1 pressed the on button, but the dryer did not activate. ADM stated the dryer is not working. ADM and S1 stated the facility dryer has not been working for about 3 weeks.

While touring the shared bathroom between bedrooms 1 & 2, LPA observed a small piece of plywood on the ceiling. (Photographs were taken). ADM stated they were planning on removing the plywood and having it match with the rest of the bathrooms ceiling this weekend.

While touring the home LPA observed the following. Bedroom #2's window does not have a screen or a sliding screen door. Bedroom #1 does not have a sliding screen door. The door across from the front door, and adjacent to the kitchen does not have a sliding screen door. Bedroom #3 windows do not have screens. The bathroom between bedroom #3 and bedroom #4 does not have a screen for its window. (Photographs were taken.)

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 75 degrees F, and hot water temperature was measured at 118 degrees F in both resident bathrooms. Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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 4
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: EMANUEL'S CARE HOME
FACILITY NUMBER: 435202852
VISIT DATE: 04/19/2024
NARRATIVE
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Fire extinguisher was serviced in December 29, 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 March 4, 2024.

LPA reviewed 3 resident records. LPA requested to see residents weight records. ADM stated the facility does weigh the residents, but they do not keep a weight record log. While reviewing R1's medication records, LPA observed 2 medications that were not listed in the centrally stored medication log. (Photographs were taken.) ADM stated it was not filled out because they were waiting for a new PRN form from San Andrea's Regional Center.

LPA reviewed facility records for 3 staff . LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records. LPA conducted interviews with 1 staff and 2 residents.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Doris Gonzalez and a copy of the signed report was provided. Appeal rights were provided.

Page 2 Out of 2.

END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/19/2024 04:50 PM - It Cannot Be Edited


Created By: Manuel Monter On 04/19/2024 at 04:21 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: EMANUEL'S CARE HOME
FACILITY NUMBER: 435202852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85075.4(a)
Observation of the Client
(a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.

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 to review the resident weight record log. ADM stated the facility has been weighing the residents, but they haven't been writing it down. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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ADM stated she will send a plan of action on how she will ensure changes in resident weights are recorded. ADM stated she will send a copy of the residents weight record , to LPA, by POC date, April 26, 2024.
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
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Based on observation, the licensee did not comply with the section cited above. LPA observed Bedroom #2's window does not have a screen. Bedroom #1 and # 2 does not have sliding screen doors. The door across from the front door does not have a sliding screen door. Bedroom #3 windows do not have screens. The bathroom between bedroom #3 and bedroom #4 does not have a screen for its window which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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ADM stated she will send a plan of action on how she will ensure all screens are in good repair. ADM stated she will send Photographs showing the screens have been placed. ADM stated she will send the plan of action by POC date, April 26, 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: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/19/2024 04:50 PM - It Cannot Be Edited


Created By: Manuel Monter On 04/19/2024 at 04:21 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: EMANUEL'S CARE HOME
FACILITY NUMBER: 435202852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) If the facility operates it own laundry, necessary supplies shall be available and equipment shall be maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above. ADM and S1 stated the facility dryer machine has not been working for 3 weeks. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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ADM stated she will send a plan of action on how she will ensure the dryer machine is functional and in good repair. ADM stated she will send the plan of aciton by POC date, April 26, 2024.
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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Based on interview and record review, the licensee did not comply with the section cited above. R1's Centrally stored medication log did not have two medications listed in the log. ADM stated she did not imput those medications becuase she was waiting for a new form from San Andreas Regional Center. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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ADM stated she will send a plan of action on how she will ensure all medications are listed on the centrally stored medication log ADM stated she will send the plan of action by POC date, April 26, 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: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4