435202897-6-4-2024-26-AS-MPAA-D5X7FC-20240604213715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202897
Report Date: 06/04/2024
Date Signed: 06/04/2024 09:40:07 PM

Document Has Been Signed on 06/04/2024 09:40 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 FEELS RESIDENTIAL CARE		FACILITY NUMBER:	435202897
ADMINISTRATOR:	SHIH, YIWEN		FACILITY TYPE:	740
ADDRESS:	781 TERRAZO DR		TELEPHONE:	(408) 224-6225
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 6	DATE:	06/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rita Garcia - Designated Administrator		TIME COMPLETED:	07:00 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	On 6/4/2024, Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted a required annual inspection and was greeted by 2 staff. License/Administrator (LIC/ADM) Yiwen (Nicole) Shih was not present and designated Administrator (DADM) Rita Garcia was not in the facility. A staff called the DADM and DADM arrived within 5 minutes. LPA stated the purpose of the visit to DADM. The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over, capacity of 6, 5 non-ambulatory and 1 ambulatory. The facility has a waiver for 2 hospice care. The facility's has 6 residents (R1 to R6) that have neurocognitive impairment. 2 staff were present at the time of the visit. 6 residents were present at the facility. 1 out of 6 were in the dining area. 1 out of 6 residents are in the backyard, 3 out of 6 were in the bedroom 2 out of 6 are non-ambulatory and 4 of 6 are ambulatory. LPA and ADM toured the facility inside and outside, including but not limited to the following: Kitchen, dining, laundry, garage, 5 resident room, 1 staff room, 2 bathrooms, backyard and the exterior walkways. The facility has access to two facilities under the same ownership. LPA checked Guardian and found that on 12/18/2023 a notice from the California Department of Social Services(CDSS), Care Provider Management Bureau (CPMB) was sent to licensee/administrator (LIC/ADM) informing the LIC/ADM that a criminal record exemption is required for S1. LIC/ADM did not submit the requirement as requested by CPMB within the given time frame. S1 stated that he/she started working at the facility 12/5/2023 and was aware of the exemption letter and requirement. S1 stated he/she passed on the letter to LIC/ADM when S1 received the letter in December of 2023. LPA discussed the importance of responding to CPMB to LIC/ADM, DADM and to S1. page 1 of 2

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

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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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 FEELS RESIDENTIAL CARE	FACILITY NUMBER: 435202897
	VISIT DATE: 06/04/2024

NARRATIVE

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At the time of record review for the facility, LIC 308 Designation of Facility Responsibility was not completed.

LPA requested the following documents: LIC 500, LIC 308, Lease Agreement, Liability Insurance, resident roster and staff background clearance record.

Deficiencies is being cited during today's visit based on California Code of Regulation, Title 22, please see LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days) for staff (S1) working at the facility without criminal record clearance or exemption. See LIC 421BG.

Due to time constraint the annual inspection will be continued at a later date. An exit interview was conducted with Designated Administrator Rita Garcia. A copy of the report and appeals rights were provided.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 06/04/2024 09:40 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: FAMILY FEELS RESIDENTIAL CARE	FACILITY NUMBER: 435202897
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...(b) shall prior to working...in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not obtaining a California clearance or criminal record exemption as required by the department for S1, prior to working in a licensed facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2024
	Plan of Correction
1 2 3 4	LIcensee/Administrator stated that they will work on the criminal record exemption for S1 prior to S1 working in the licensed facility. The licensee stated understanding of the requirement and will submit the plan of correction on the due date.

Type A

Section Cited

CCR

87405(d)(1)(2)

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). The licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review,LIC/ADM did not comply with the section cited above. The LIC/ADM diid not adhere to the requirement and conform to the applicable laws, rules and regulations. LIC/ADM stated that he/she is not aware S1's exemption was not processedt and a board resolution for permanent designated administrator was not submitted to licensing, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2024
	Plan of Correction
1 2 3 4	LIC/ADM stated a designation of facillity responsibility (LIC 308) will be submitted to licensing and requirement for S1s exemption will be provided, LIC 308 and a board of resolution will be submitted to licensing for designation of facility responisbility on the plan of correction due date. LIC/ADM stated understanding of the requirement.

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	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC809 (FAS) - (06/04)

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