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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202876
Report Date: 01/24/2025
Date Signed: 01/24/2025 03:38:30 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/24/2025 03:38 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:FAMILY SENIOR CARE HOME IFACILITY NUMBER:
435202876
ADMINISTRATOR/
DIRECTOR:		BAUTISTA, ELIZABETHFACILITY TYPE:
740
ADDRESS:2898 GLEN FROST COURTTELEPHONE:
(408) 802-7727
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator, Elizabeth BautistaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management for annual continuation from 1/23/2025. LPA Rai met with Administrator, Elizabeth Bautista and stated the purpose of today's visit.

The hot water temperature in the bathroom sink ranged from 105.1 - 105.3 degrees F.

Fire extinguisher was observed and inspected on 1/24/2025. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills were conducted on 1/7/2025 and 1/9/2025.

LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai observed resident R2 with a full bed rail. ADM stated R2 was not receiving Hospice care at this time. LPA Rai reviewed R2's facility file and R2 did not have a written physician's order for full bed rail or half bed rail. ADM stated she will work with R2's physician to obtain a written physician's order for half bed rail and remove the full bed rail from R2's bed.

LPA Rai observed R3, R4, and R5 with half bed rails who are not receiving Hospice care at this time. LPA Rai reviewed R3, R4 & R5's facility file and they did not have a written order from physician for using a half-bed rail for mobility use. ADM stated she will work with the resident's physician's to obtain a written physician's order for half-bed rails.

LPA Rai reviewed R5's facility file and reviewed a medical assessment conducted on 6/13/2023 and ADM stated R5 was not recently seen by physician. ADM will work with R5's responsible party and physician for R5 to receive an annual routine visit with physician.

Continuation on LIC 809-D, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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
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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876
VISIT DATE: 01/24/2025
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LPA Rai reviewed R5's Appraisal/Needs and Services Plan was not signed by R5's responsible party. ADM stated to work with R5's responsible party and a signed copy of the document will be added to R5's file.

LPA Rai observed 2 bottles of OTC medications in R2's room and 1 bottle of prescription medication in R4's room. LPA Rai reviewed Physician's Report for R2 and R4 and both residents cannot store medications on their own and require medications to be centrally stored at the facility. ADM removed the items during the visit and placed medications in the medication cabinet.

LPA Rai reviewed resident medications and central stored medication records.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC 809-D.

Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator Elizabeth Bautista and a copy of the report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/24/2025 03:38 PM - It Cannot Be Edited


Created By: Simranjit Rai On 01/24/2025 at 02:15 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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87608(a)(5)(B)

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87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care...
This requirement is not met as evidenced by:
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Administrator stated to submit a written plan of action of understanding regulation and remove the full bed rail and ask for written physician’s order for half-bed rail and place a half-bed rail on R2’s bed by POC due date.
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Based on record review and observation, R2 has a bed rail that extended the entire length of the bed and R2 is not receiving hospice care at this time which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/31/2025
Section Cited
CCR87608(a)(3)

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87608 Postural Supports (a)(3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record....
This requirement is not met as evidenced by:
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Adminstrator stated to submit a written plan of action of understanding reglulation and obtain a written order from resident's physician for half-bed rail to be used for mobility by POC due date.
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Based on observation and record review, 3 out of 5 residents used a half bed rail and did not have a written order from a physician on file which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/24/2025 03:38 PM - It Cannot Be Edited


Created By: Simranjit Rai On 01/24/2025 at 02:18 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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care (h) (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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Administrator stated to submit a written plan of action of understanding regulation and provide staff training to ensure centrally stored medications are kept in a safe and locked place inaccessible to residents by POC due date.
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Based on observation and record review, 3 medication bottles were not kept in a safe and locked place which is not accessible to persons other than employees which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/31/2025
Section Cited
CCR87463(h)

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87463 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:
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Administrator stated to submit a written plan of action of understanding regulation and schedule an appointment with R5's physician to complete an updated medical assessment by POC due date.
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Based on record review, R5's file contained a medical assessment completed on 6/13/2023 and there was no other documentation of R5 receiving an annual routine visit with R5's physician which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/24/2025 03:38 PM - It Cannot Be Edited


Created By: Simranjit Rai On 01/24/2025 at 02:25 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: FAMILY SENIOR CARE HOME I
FACILITY NUMBER: 435202876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87463(f)

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87463 Reappraisals (f) The licensee shall ...communicate with the resident and,... the resident's representative, about any significant change in condition and the recommendation... Documentation of such communication shall be added to the resident’s record.
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Administrator stated to submit a written plan of action understanding regulation and to follow up with R5's responsible party to sign the Appraisal/Needs and Services Plan by POC due date.
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This requirement is met as evidenced by:
Based on record review of R5's Appraisal/Needs and Services Plan was not signed by R5's responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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