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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294105
Report Date: 06/06/2024
Date Signed: 06/06/2024 12:45:34 PM


Document Has Been Signed on 06/06/2024 12:45 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:LEE'S CARE HOMEFACILITY NUMBER:
435294105
ADMINISTRATOR:CORAZON MILLARESFACILITY TYPE:
740
ADDRESS:5225 GALLANT FOX AVE.TELEPHONE:
(408) 841-9508
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:6CENSUS: 5DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Corazon MillaresTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Corazon Millares.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area and found locked drawers for medications, sharps, and cleaning supplies. LPA Marrufo observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA Marrufo observed the first aid kit and found it to be complete.

LPA Marrufo toured the outside area and found the exits to be clear of obstructions. LPA Marrufo toured 3 out of 3 resident bedrooms and observed each bedroom had available bedding and storage areas and functioning lights. LPA Marrufo tested the smoke detectors in each bedroom and in the hallway areas and found them to be functioning properly when tested. The carbon monoxide detector also functioned properly when tested.

LPA Marrufo toured the resident bathroom and observed the water temperature to be 106 F. The bathroom had working lights and available soap and paper towels.

LPA Marrufo reviewed the Centrally Stored Medication Logs for 5 out of 5 residents and found them to be complete. LPA Marrufo reviewed 5 out of 5 resident records and observed residents R1 and R2 have dementia and have Physician's Reports that were more than 1 year old. R1's Physician's Report was from 02/04/2019 and R2's Physician's Report was from 09/22/2021. Staff records were reviewed and found to be complete. A deficiency was cited as per California Code of Regulations. See LIC809-D for more information.

This report was reviewed with Millares Corazon and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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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Document Has Been Signed on 06/06/2024 12:45 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: LEE'S CARE HOME
FACILITY NUMBER: 435294105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia (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
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Based on review of resident records, LPA Marrufo observed 2 out of 2 residents with dementia did not have Medical Assessments (Physician's Reports) that were completed within one year, which poses a potential safety risk to residents in care.
POC Due Date: 06/13/2024
Plan of Correction
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Licensee agrees to update the Physician's Report for residents R1 and R2 and submit copies of the updated Physician's Reports to CCL by POC 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: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
LIC809 (FAS) - (06/04)
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