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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202877
Report Date: 02/14/2024
Date Signed: 02/14/2024 02:09:15 PM


Document Has Been Signed on 02/14/2024 02:09 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:ANDREA'S ELDERLY CARE FACILITY 1FACILITY NUMBER:
435202877
ADMINISTRATOR:VALDEZ, JOWELLFACILITY TYPE:
740
ADDRESS:804 HAMANN DRIVETELEPHONE:
(408) 490-4758
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:12CENSUS: 11DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Licensee Felina RoqueTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Licensee (LN) Felina Roque. During the visit, LPA observed 11 residents and 3 staff.

LPA toured the facility inside out with LN which included the Living room, kitchen, dining room, 3 restrooms and 9 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.

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 118 degrees F in resident bathrooms.

Fire extinguisher was serviced in October 20, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by LN, and were functional. LPA observed facility first aid kit and requested to review facility fire/earthquake drill log. LN stated the last drill conducted was last month, but LN stated they don't have a log.

LPA reviewed facility records for 3 residents. While reviewing residents R1-R3 records, LPA observed R1 and R3 did not have a weight record. Resident R2 is missing two months of weight record documentation. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed facility records for 3 staff. LPA conducted interviews with 2 staff (S1 to S2) and 2 residents (R1-R2).

Deficiencies are being cited during today's visit, see LIC 809-D. This report was reviewed with Licensee Felina Roque and a copy of the signed report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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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Document Has Been Signed on 02/14/2024 02:09 PM - It Cannot Be Edited

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: ANDREA'S ELDERLY CARE FACILITY 1
FACILITY NUMBER: 435202877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. LPA observed R1 and R3 did not have a weight record. Resident R2 is missing two months of weight record documentation. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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ADM stated she will send plan of action on how the facility will ensure residents changes of weight are observed. ADM stated she will create a weight record log and will send plan of action by POC date, 02/21/2024.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. LN stated the facility does conduct drills but did not document the drills. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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ADM stated she will create a disaster drill log. ADM stated she will send documentation to LPA that a drill has taken place by POC. ADM stated she will send plan of corrections by POC date, 02/21/2024.
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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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