435202883-11-14-2024-26-AS-MYAZ-DB23NL-20241114172406

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202883
Report Date: 11/14/2024
Date Signed: 11/14/2024 05:24:29 PM

Document Has Been Signed on 11/14/2024 05:24 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:	MINA'S ELDERLY CAREHOME 2		FACILITY NUMBER:	435202883
ADMINISTRATOR/ DIRECTOR:	GIMENO, MICHAEL		FACILITY TYPE:	740
ADDRESS:	15095 GARDEN HILL DRIVE		TELEPHONE:	(408) 348-8361
CITY:	LOS GATOS	STATE: CA	ZIP CODE:	95032
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:28 PM
MET WITH:	Mina Abbasvand		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst LPA Marcela Yanez and Licensed Progam Manager LPM Romeo Manzano conducted an unannounced annual inspection visit, and met with Mina Abbasvand During the visit, LPA observed 5 residents and 3 staff. LPA explained the purpose of the visit. the facility is approved for 6 non-ambulatory, 1 which may be bedridden, room #2 is designated as bedridden, hospice waiver approved for 2 residents LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms that had grab bars and non skid mats and 3 residents bedrooms. During tour LPA observed a bottle of mouthwash in the bathroom accessible to residents with dementia, LPA suggested to lock in cabinet. While touring the facility LPA observed residents doing activity and other resident reading a book as well as watching television. During inspection LPA observed 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 120 degrees F in both resident bathrooms and in kitchen sink was 121.0 F degrees. The staff bedroom was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways and ramps and sturdy. Page 1 of 2

Romeo Manzano	TELEPHONE: (650) 388-2297
Marcela Yanez	TELEPHONE: (279) 789-1062
	DATE: 11/09/2024

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)

Page: 1 of 3

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: MINA'S ELDERLY CAREHOME 2	FACILITY NUMBER: 435202883
	VISIT DATE: 11/14/2024

NARRATIVE

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LPA observed 2 exit doors leading from bedroom #2 leading to living room and leading to laundry area. ADM stated she will place a sign stating the bedroom should not be used as a passage way for resident privacy. LPA also observed oxygen in bedroom # 1 resident (R1) who is under hospice care with oxygen. LPA advised to post a "oxygen in use-no smoking" sign

Fire extinguisher was serviced in 4/18/2024. 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 11/05/24

LPA observed a storage shed with no electrical wiring approximately 12x12 feet in the backyard with a window with a bed, clothing and personal belonging to Staff (S1). S1 was not present during visit. ADM stated the S1 does not live or sleep in the shed only stores his/her belongings.

LPA reviewed facility records for 4 staff and 3 residents. 1 of 3 residents with dementia Appraisal Needs and Services was not updated within the last year last updated was 11/4/2022. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 3 staff and 2 residents.

Deficiencies cited during today's visit (see 809-D) This report was reviewed with Mina Abbasvand and a copy of the signed report was provided and a copy of Appeals Rights were provided.

End of Report

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela Yanez	TELEPHONE: (279) 789-1062
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: 2 of 3

Document Has Been Signed on 11/14/2024 05:24 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: MINA'S ELDERLY CAREHOME 2	FACILITY NUMBER: 435202883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation record review, the licensee did not comply with the section cited above. During review iof resident file, Resident (R1) LIC 625 was last updated on 11/04/2022 who has dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2024
	Plan of Correction
1 2 3 4	ADM stated she will update R1 LIC 625 on or before POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

Romeo Manzano	TELEPHONE: (650) 388-2297
Marcela Yanez	TELEPHONE: (279) 789-1062
	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: 3 of 3