435202897-6-7-2024-26-AS-MPAA-D625KK-20240607200139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202897
Report Date: 06/07/2024
Date Signed: 06/07/2024 08:01:54 PM

Document Has Been Signed on 06/07/2024 08:01 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:	06/07/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Rita Garcia - Designated Administrator		TIME COMPLETED:	02:45 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 6/07/2024 at 1:00 p.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management for Annual continuation and was met by Designated Administrator (DADM) Rita Garcia. The Administrator(ADM) Yiweh (NIcole) Shih was not present at the time of the visit. DADM called ADM and asked if ADM can come to the facility. ADM stated he/she is not available due to prior commitment. During today's visit LPA observed that 6 out of 6 residents are resting and are currently in their respective bedrooms. 4 out of 6 residents have neurocognitive impairment, 2 out of 6 has mental impairment. On 6/4/2024, LPA with DADM toured the facility inside and out, such as kitchen, dining, living area, backyard, resident's room, bathrooms, entry way, staff room and office. The facility has 5 resident bedroom, 1 of the 5 bedroom is shared and 4 are private. LPA observed a sign on the entry way that oxygen is in use. DADM stated that the oxygen is used by 1 Out of 6 resident (R1) on as needed basis. LPA observed a sign on the entry way that oxygen is in use. DADM stated that the oxygen is used by 1 Out of 6 resident (R1) on as needed basis. LPA observed the Personal Rights disclosure, Long Term Care Ombudsman (LTCO) and Centralized Complaint and Information Bureau (CCIB) of the CA Department of Social Services (CDSS) prominently posted on the wall, visible to visitors, resident and staff. The temperature inside the home was at 68 to 70.1 degrees F. LPA observed the kitchen to be organized, and sanitary with working appliances. Knives were kept in a secure locked area and not easily accessible to residents. The laundry room has a lock, and staff room is The facility has 2 days of perishable food and 7 days of non-perishable food. page 1 of 3

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

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: 06/07/2024

NARRATIVE

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LPA inspected the residents' bedrooms and found that 5 out of 5 rooms have furniture and closet space for resident's personal belongings, bed frames with mattress and bed linens. 5 Out of 5 resident room is sanitary, organized and are free from debris. LPA observed that the 3 Out of 3 bathrooms have dark stains on the wall tile inside the shower area, water stains, rust on the shower floor, stains on the toilet bowls, sink, faucet, trash bins and floor.

LPA with ADM tested the water temperature for kitchen and bathrooms, water temperature was measured at 107.6 degrees F to 116.2 degree F.

LPA with DADM inspected the laundry area and observed washer and dryer are in good working condition. LPA observed that the medication is in a locked cabinet. The facility has a first aid cabinet with first aid supplies and accessible to staff.

The side door and sliding door to access the backyard opens easily and are free from obstruction. LPA observed ramps and walkways are free from obstruction. LPA observed the backyard area to be free from debris and is maintained. The facility is in a compound with two other facility under the same ownership.

LPA reviewed facility record and 1 out of 2 staff were found to have no criminal clearance exemption and was cited on the initial visit on 6/4/2024. During today's visit LPA reviewed 2 out of 2 staff record 3 out of 6 resident record and facility records. LPA reviewed the facility record, the disaster training has not been conducted since the facility got licensed on 6/16/2023. Staff training records were up to date, Staff records were reviewed with current first aid certifications, 1 out of 2 have a valid CPR, first aid training. Residents files were reviewed to be complete. Residents' medications are labeled and current.

LPA reminded LPA requested updated documents, LIC 500, lease agreement, updated liability insurance and LIC 308 and the Summer Wellness Preparedness readiness that is available online for the DADM and ADM to discuss and train staff.

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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: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: 06/07/2024

NARRATIVE

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at 5:00 p..m. LPA with DADM Rita Garcia spoke with LIcensee/ Administrator(LIC/ADM) Yiwen (Nicole) Shih by phone and discussed the deficiencies cited during today's visit. LIC/ADM stated understanding and will have a plan to correct the deficiencies by the due date.

Deficiencies are cited during today's visit based on the California Code of Regulations (CCR) Title 22, see LIC 809D. An exit interview was conducted with designated administrator (DADM) Rita A Garcia. A copy of the report and appeals rights were provided.

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end of report

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 06/07/2024 08:01 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: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)(1)

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, ...shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above by not maintaining floor and sink surfaces in bath clean and sanitary which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/08/2024
	Plan of Correction
1 2 3 4

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.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC809 (FAS) - (06/04)

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