435294147-7-27-2024-26-AS-MPAA-D7L423-20240727184227

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294147
Report Date: 07/27/2024
Date Signed: 07/27/2024 06:42:53 PM

Document Has Been Signed on 07/27/2024 06:42 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:	ALL ABOUT SENIORS ELDERLY CARE		FACILITY NUMBER:	435294147
ADMINISTRATOR:	KENDALL HALL		FACILITY TYPE:	740
ADDRESS:	1319 MARIA WAY		TELEPHONE:	(408) 483-2433
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	6	CENSUS: 4	DATE:	07/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Annabelle B Esperanza Designated Administrator		TIME COMPLETED:	06:40 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 7/27/2024 at 2:00 p.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced, required 1 year inspection at the facility and met with the designated administrator (DADM) Annabelle Esperanza. At the time of the visit, DADM stated that licensee/administrator (LIC/ADM) Debra Hall is currently unable to come to the facility due to physical injury requiring rest. The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over. 6 may be non-ambulatory. The facility has a waiver for 3 hospice care. The facility's has 4 residents (R1 to R4) that have neurocognitive impairment. 3 staff were present at the time of the visit. 4 residents were present at the facility. 2 of 4 were in the dining area. 2 of 4 residents are in the bedroom and 2 of 4 are under hospice care. At 2:15 p.m.. LPA with DADM, toured the facility inside and outside, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, backyard and walkways. 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 78 degrees F. LPA and DADM toured the 4 resident bedrooms and LPA observed the rooms to be organized and free from debris and has sufficient storage for resident's personal belongings. Residents uses an alarm system to alert staff if assistance is needed and a motion sensor alarm on the bed. ADM stated the facility has a night on call staff if a resident is awake, and staff stays with the resident. LPA observed that the facility has a wall pull fire alarm system connected to the fire department emergency line and a carbon monoxide alert system that is in good working condition. LPA observed night lights on the hallway. Hallways are free from obstruction. page 1 of 3 (SEE LIC 809C).

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

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 5

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: ALL ABOUT SENIORS ELDERLY CARE	FACILITY NUMBER: 435294147
	VISIT DATE: 07/27/2024

NARRATIVE

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LPA observed that each resident room has a door to access the backyard, doors and sliding doors open easily and free from obstruction. LPA observed the backyard area to be free from debris. However, LPA observed the following, screen doors were broken and needs to be replaced, for R1 to R3, the backyard storage shed door was broken. LPA observed that the sliding door base are not flushed to the floor reducing ease of access.

LPA observed that 4 of 4 resident room have a half bath. LPA observed non-skid mats and grab bars and a raised toilet seats with handles. LPA with ADM tested the water temperature for kitchen and bathrooms, water temperature was measured at 107.9 degree F.

LPA observed dining and kitchen area and living room area were observed to be sanitary and organized. However, the knives were not locked but hidden and obscured by paper shopping bags. DADM stated that the cabinets are currently being changed and locks will be installed once kitchen cabinets installation are completed. LPA observed that the stove was sanitary, however, the vent screen has accumulated residue from oil and dust.

LPA observed that the cabinet door under the sink when opened comes off the hinge. The laundry room and cleaning supplies are locked securely inside the water heater cabinet. LPA observed an open electrical ground inside the cabinet utilized as the laundry room, water heater tank, and chemical storage. The facility has sufficient supply of perishable food for 2 days and non-perishable food for 7 days. The fire extinguisher located in the kitchen was last inspected and maintained on 8/18/2022.

LPA observed that some of the medication are in a locked cabinet, however the other half are inside a cabinet that has broken door and lock does not work, therefore, R1 to R4s medications cannot be locked. The facility has a first aid kit that is complete and accessible to staff.

LPA reviewed facility record and observed that the disaster training was last done on 2/20/2023. The LIC 500 needs to have specific time and date for each person even when on call, and the LIC 308, needs to be updated. LPA discussed the records with DADM regarding disaster training, LIC 500 and LIC 308.

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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: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: ALL ABOUT SENIORS ELDERLY CARE	FACILITY NUMBER: 435294147
	VISIT DATE: 07/27/2024

NARRATIVE

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LPA with DADM, reviewed 2 of 2 staff record and 3 of 3 resident record and facility records.
Staff training records were up to date. Staff records were reviewed with current first aid certifications, clearance and training. Residents files were reviewed to be complete. Residents' medications are labeled and current.

Deficiencies are cited during today's visit based on California Code of Regulations (CCR) Title 22. See LIC 809D. An exit interview was conducted with DADM Annabelle Esperanza. 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: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5

Document Has Been Signed on 07/27/2024 06:42 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: ALL ABOUT SENIORS ELDERLY CARE	FACILITY NUMBER: 435294147
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(k)(3)

87705 Care of Persons with Dementia (k)The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: (3)Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. 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 conducting fire and earthquake drills once every 3 months as required for care of persons with dementia. The last fire and earthquake drill was conducted on 2/20/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	DADM stated that a fire and earthquake drill will be conducted by Monday 7/29/2024 and will email proof training of all staff by the POC due date.

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: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 07/27/2024 06:42 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: ALL ABOUT SENIORS ELDERLY CARE	FACILITY NUMBER: 435294147
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)(2)

87705 Care of Person with dementia. (f) The following shall be stored inaccessible to residents with dementia: (1) Knives...(2)Over-the counter medication... supplements..This requirement was not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, DADM did not ensure that medications cabinet located in the office area & knives located in the kitchen are inaccessible to persons with dementia. The medication cabinet lock was broken and medications are easily accessible. The drawer that stores the knives does not have a lock, which pose/poses an immediate health, safety and personal right risk to persons in care.
	POC Due Date: 07/28/2024
	Plan of Correction
1 2 3 4	DADM stated that the locks will be addressed by one of the administrators who maintains the facility and lock storage cabinets to ensure medications and knives are secured and not accessible.

Type A

Section Cited

CCR

87303(a)(c)

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. (c) All window screens shall be clean and maintained in good repair. 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 ensuring that screens are repaired in R1, R2 and R3s bedroom sliding door. The sliding door base is not flushed to the floor reducing the ease of access to the exterior. The kitchen cabinet door under the sink is broken and the pots and pan cabinet was missing a door. The vent has residue of dust and oil, which poses an immediate health, safety and personal right risk to persons in care.
	POC Due Date: 07/28/2024
	Plan of Correction
1 2 3 4	DADM stated that the ease of access and the frayed screen doors will be addressed by one of the admiistrator who handles facility maintenance. A plan on how and when to address the access will be submitted by the plan of correction due date.

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: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

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