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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294079
Report Date: 01/30/2024
Date Signed: 01/30/2024 05:30:17 PM


Document Has Been Signed on 01/30/2024 05:30 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:RIVER PARK HOMES IIFACILITY NUMBER:
435294079
ADMINISTRATOR:GARCIA, AMPARO QUEFACILITY TYPE:
740
ADDRESS:3427 GILA DRIVETELEPHONE:
(408) 270-4060
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 5DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Amparo GarciaTIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Designated Administrator, Justina Nicholas and Licensee, Amparo Garcia.

During visit, LPA toured the facility with Designated Administrator, Justina Nicholas to include the dining room, kitchen, living room, resident rooms, bathrooms, staff room, garage, and backyard. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared and associated to the facility.

Facility temperature maintained at 71 degrees Fahrenheit. Fire extinguisher last serviced on 03/25/2023. LPA did not observe an operable carbon monoxide detector present. During visit, Licensee left the facility to purchase a carbon monoxide detector and installed the device during visit. Posters observed at the entrance to include an 8x10 complaint poster sign, ombudsman poster, COVID-19 related posters, and personal rights.

Kitchen refrigerator maintained at 48 degrees Fahrenheit. Licensee was advised. Freezer maintained at 0 degrees Fahrenheit. Medications, sharp objects, chemicals and disinfectants observed locked.

Resident bedrooms equipped with beds, linens, adequate lighting, chair, night stands, and dressers. 3 residents observed with half bed rails. LPA observed a physician's order for 3 out of 3 residents. 1 resident observed using an oxygen concentrator. The resident's file contains a physician's order. Licensee was advised to place an "oxygen in use" next to the residents bedroom. LPA observed an oxygen in use sign was posted at the front door. SEE LIC809-C.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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 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: RIVER PARK HOMES II
FACILITY NUMBER: 435294079
VISIT DATE: 01/30/2024
NARRATIVE
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Bathroom supplied with hygiene products, paper supplies, lidded trash bins, and non-slid mats. LPA observed the hot water temperature in room #4 to be maintained at 109 degrees Fahrenheit. LPA observed the facility's hot water pressure for the sink and shower was very low in the bathroom located in the hallway. LPA observed that bathroom's hot water temperature takes more than 5 minutes to heat up. LPA measured the hot water temperature to be maintained at 100 degrees Fahrenheit. LPA observed the hot water pressure in room #1 was also very low. LPA observed the hot water temperature in that room also takes more than 5 minutes to heat up. LPA observed the hot water temperature in Room #1 to be maintained at 100 degrees Fahrenheit. Licensee states awareness of the issues with the facility's hot water temperature and hot water pressure. Licensee states they started having issues with the water in summer of 2023. Licensee states when the residents requests for warmer water for their baths, they'd boil water to create warmer water. Licensee was advised.

LPA reviewed 3 residents (R1 - R3)'s records to include an admission agreement, physician's report, TB result, updated appraisal/needs and services plan, emergency identification form, safeguard of personal properties, personal rights, and centrally stored medication records.

LPA reviewed 3 staff (S1 - S3) records. S1 - S3 files contains an updated 1st aid certification, health screening, TB results, and employee rights. During visit, the facility was unable to produce the staff annual training documentation to include annual training on dementia care, postural supports, and restricted health conditions. Licensee states the staff has been provided annual training, however, the training documentation is located in another location. The facility showed LPA staff training on hospice care which equaled 4 hours of training. Licensee was advised. Facility staff are trained on infection control practices.

Facility conducts emergency drills quarterly. The last emergency drill conducted was dated in December 2023. Facility has an updated emergency disaster plan. Facility has a first aid kit. Facility has extra flashlights.

Deficiencies are being cited per California Code of Regulations, Title 22. SEE LIC809-D. Advisory notes provided. This report was reviewed with Licensee, Amparo Garcia and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/30/2024 05:30 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: RIVER PARK HOMES II
FACILITY NUMBER: 435294079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the facility's water pressure in 2 out of 3 bathrooms are very low and the hot water takes more than 5 minutes to heat which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Licensee will try to fix the water pressure before contacting a contractor. Licensee will send LPA Dolores the results of her plan in writing to fix the water pressure in 2 out of 3 bathrooms by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 01/30/2024 05:30 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: RIVER PARK HOMES II
FACILITY NUMBER: 435294079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review licensing program analyst (LPA) Dolores was unable to review the facility's training documentation because they were located in another location, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2024
Plan of Correction
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Licensee will submit a statement of understanding of the section cited above to LPA Dolores by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4