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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202891
Report Date: 12/03/2024
Date Signed: 12/04/2024 01:20:08 PM

Document Has Been Signed on 12/04/2024 01:20 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:RGK HOME CAREFACILITY NUMBER:
435202891
ADMINISTRATOR/
DIRECTOR:		LAZARO, MARY GRACE V.FACILITY TYPE:
740
ADDRESS:274 CLEARPARK CIRCLETELEPHONE:
(408) 420-7262
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 5DATE:
12/03/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH: Ravenal Cruz and Mary Grace LazaroTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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A noncompliance meeting was conducted on 12/03/2024 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analyst Steve Chang, Manuel Monter, Marcela Yanez, facility Administrator Mary Grace Lazaro, facility Licensee Ravenal Cruz, and facility House Manager Annie Rose..

The purpose of the noncompliance meeting was to discuss substantiated complaint allegations. Deficiencies were cited for violations of Title 22 California Code of Regulations on 9/17/2024: 87468.1(a)(2), Personal Rights of Residents in All Facilities and 87211(a)(1)(D), Reporting Requirements

On 05/31/2024 and 9/17/24, the Department conducted investigation regarding an elopement of a resident with developmental disability and neurocognitive disorder. The deficiency issued under Title 22 Regulations 87468.1(a)(2), Personal Rights of Residents in All Facilities was inadvertently issued a Type B instead of Type A. Type A violation is an immediate risk to the safety and health of residents. During the meeting, licensees were informed that the citation issued on 9/17/24, LIC9099-D, Title 22, Code section 87468.1(a)(2) will be amended from Type B to Type A.

Noncompliance Conference Summary LIC 9111 and compliance plans were established during the meeting. The facility will begin a 2-year monitoring plan by licensing which includes more frequent licensing inspections.

Report was reviewed with facility Licensee. A copy of this report, LIC 9111 and LIC 809-D deficiencies were issued and were provided to licensees during today's office visit. During visit, LPA provided a copy of CCL New Dementia Care Regulations Flier and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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
Document Has Been Signed on 12/04/2024 01:20 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 12/03/2024 at 10:10 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: RGK HOME CARE
FACILITY NUMBER: 435202891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2024
Section Cited
CCR
87463(a)

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87463 Reappraisals(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. ....
This requirement was not met as evidenced by:
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ADM and Licensee stated they will conduct a meeting with responsible party and staff and update re-apprisal for R1 and all residents as frequently as possible to ensure accuracy. Review all residents needs and services plan for all residents at least every 3 months and as needed,
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Based on the interviews and records reviewed on 5/31/2024, R1's appraisal needs and service plan was not updated after R1's elopement on 5/21/2024, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care
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Type A
12/04/2024
Section Cited
CCR87405(d)(1)

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in ....(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.

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ADM / Licensee stated they will conduct additional training for staff and themselves, regarding elopment, dementia, and re-apprisals. ADM and Licensee stated they will enroll in dementia training and other behavioral training.
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Based on R1's elopement on 5/21/2024, Administrator did not fulfill his/her duites & responsibility for providing care and supervision for R1. This poses/posed an immediate 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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/04/2024 01:20 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 12/03/2024 at 03:03 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: RGK HOME CARE
FACILITY NUMBER: 435202891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2024
Section Cited
CCR
87464(f)(1)

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87464 Basic Services (f)Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as as evidenced by:
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ADM stated they will make sure to check the residents every 15 mintues and check the doors. ADM stated they will also replace the door alarms as well.
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Based on the interview with 3 staff (S1-S3), did not ensure R1's bedroom door was closed and the door alarm did not activate to alert staff when R1 left from the facility which poses/posed an immediate 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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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